Nursing Elites

1. A client who had coronary artery bypass grafting yesterday needs care. What actions can the nurse delegate to the unlicensed assistive personnel (UAP)? (SATA)

• A. administer antibiotics every 4 hrs
• B. Encourage the client to use the spirometer every 4 hours.
• C. Ensure the client wears TED hose or sequential compression devices.
• D. Have the client rate pain on a 0-to-10 scale and report to the nurse.

Correct answer: C

Rationale: The nurse can delegate tasks such as assisting the client to get up in the chair or ambulate to the bathroom, applying TED hose or sequential compression devices, and taking/recording vital signs to the unlicensed assistive personnel (UAP). Using the spirometer should be encouraged every hour the day after surgery by the nurse. Assessing pain using a 0-to-10 scale is a nursing assessment. However, if the client reports pain, the UAP should inform the nurse for a more detailed assessment.

2. A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

• A. Insert an indwelling urinary catheter.
• B. Inspect the mouth for signs of inhalation injuries.
• C. Administer intravenous pain medication.
• D. Draw blood for a complete blood cell (CBC) count.

Correct answer: B

Rationale: When caring for a client with burns, especially burns to the face and chest, the priority action for the nurse is to inspect the mouth for signs of inhalation injuries. Inhalation injuries can be life-threatening and may not be immediately apparent. Identifying these injuries early allows for prompt intervention and can significantly impact the client's outcomes. While other actions such as pain management and blood tests are important, assessing for inhalation injuries takes precedence due to its critical nature.

3. While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?

• A. 100% of meals being eaten by the client
• B. Intact skin behind the ears
• C. The client understanding the need for oxygen
• D. Unchanged weight for the past 3 days

Correct answer: B

Rationale: When a client is using oxygen, there is a risk for impaired skin integrity due to pressure from tubing. Intact skin behind the ears suggests that the client is not experiencing skin breakdown, meeting the goals for this diagnosis. The client's nutrition, understanding of oxygen therapy, and weight stability are important but do not directly relate to the priority diagnosis of skin integrity in this context.

4. After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?

• A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate.
• B. Crackles are heard in bases. The nurse encourages the client to cough forcefully.
• C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
• D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.

Correct answer: C

Rationale: Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages, making option C the correct match. Wheezes are typically heard in the central or peripheral lung areas and are associated with conditions like asthma or COPD. Inhaled bronchodilators work by dilating the bronchioles, which helps alleviate wheezing and improve airflow. Therefore, administering an inhaled bronchodilator is the appropriate intervention in response to wheezes.

5. A client has developed atelectasis postoperatively. Which of the following findings should the nurse expect?

• A. Facial flushing
• B. Increasing dyspnea
• C. Decreasing respiratory rate
• D. Friction rub

Correct answer: B

Rationale: Atelectasis is a condition where the alveoli in the lungs collapse, leading to impaired gas exchange. As a result, the client may experience increasing dyspnea (difficulty breathing) due to the decreased lung capacity for oxygen exchange. Facial flushing, decreasing respiratory rate, and friction rub are not typically associated with atelectasis.

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