Nursing Elites

1. A client with a chest tube following thoracic surgery needs care. Which task should the nurse delegate to an assistive personnel?

• A. Teach deep breathing and coughing to the client.
• B. Assist the client to select food choices from the menu.
• C. Evaluate the client’s response to pain medication.
• D. Monitor the characteristics of the client's chest tube drainage.

Correct answer: B

Rationale: The correct answer is B because assisting the client with food choices is a task that can be safely delegated to assistive personnel. This task does not require nursing judgment or specialized skills. Choices A, C, and D involve assessing the client's condition, response to treatment, and monitoring critical aspects of care, which are nursing responsibilities that necessitate specialized knowledge and judgment. Teaching deep breathing and coughing (A), evaluating pain medication response (C), and monitoring chest tube drainage (D) require a higher level of training and expertise that should be performed by the nurse.

2. A client is being taught how to care for their tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

• A. Use tracheostomy covers when outdoors.
• B. Clean the tracheostomy site with hydrogen peroxide daily.
• C. Change the tracheostomy tube weekly.
• D. Apply ointment around the tracheostomy site.

Correct answer: A

Rationale: The correct instruction is to use tracheostomy covers when outdoors. Tracheostomy covers serve to protect the airway from environmental contaminants, reducing the risk of infection. Choice B is incorrect because hydrogen peroxide can be irritating to the skin and is not recommended for cleaning the tracheostomy site. Choice C is incorrect as tracheostomy tubes should not be routinely changed weekly unless there is a specific medical indication. Changing it without a need can introduce infection or damage the stoma. Choice D is incorrect as applying ointment around the tracheostomy site can lead to occlusion of the stoma and interfere with breathing.

3. A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority?

• A. “I kind of like this boy in my class, but he doesn’t like me back.”
• B. “I want to hang out with the kids in the science club, but the jocks pick on them.”
• C. “I am so fat, I skip meals to try to lose weight.”
• D. “My dad wants me to be a lawyer like him, but I just want to dance.”

Correct answer: C

Rationale: The correct answer is C. Skipping meals to lose weight may indicate an eating disorder or significant distress, which can have serious health implications. This behavior raises concerns about the adolescent's physical and mental well-being. The nurse should prioritize addressing potential eating disorders and body image issues in this situation. Choices A, B, and D, while important, do not pose an immediate risk to the adolescent's health or well-being compared to the potential consequences of disordered eating behavior.

4. The nurse manager hears a healthcare provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the healthcare provider's complaints. The nurse manager's next action should be to

• A. Approach the healthcare provider and staff nurse for a private meeting to address the situation.
• B. Allow the staff nurse to handle this situation without interference.
• C. Notify other administrative personnel of a breach of professional conduct.
• D. Request an immediate private meeting with the healthcare provider and staff nurse.

Correct answer: D

Rationale: The correct action for the nurse manager in this situation is to request an immediate private meeting with the healthcare provider and staff nurse. By doing so, the nurse manager can facilitate a more appropriate and professional discussion of the issues at hand in a private setting. Option A, which involves addressing the behavior quietly, may not effectively resolve the issue as it needs to be openly discussed. Option B is not advisable as the nurse manager should intervene to address the situation and provide support. Option C, notifying other administrative personnel, may escalate the situation unnecessarily before attempting to resolve it directly with the involved parties.

5. The nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use?

• A. Supine position
• B. Lateral position
• C. Lateral position with positioning supports
• D. Supine position with no pillow under the patient's head

Correct answer: B

Rationale: When assessing body alignment for an immobilized patient, the nurse should use the lateral position. This position helps in assessing alignment and preventing complications such as pressure ulcers. The supine position (Choice A) may not provide an accurate assessment of body alignment in an immobilized patient. While a lateral position with positioning supports (Choice C) may be used for comfort, it is not specifically for assessing body alignment. Using the supine position without a pillow under the patient's head (Choice D) is not ideal for assessing body alignment in an immobilized patient as it may not accurately reflect the patient's overall alignment.

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