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. After performing foot care, the nurse checks the medical record and discovers that the patient has a disorder on the sole of the foot caused by a virus. Which condition did the nurse most likely observe?

• A. Corns
• B. A callus
• C. Plantar warts
• D. Athlete's foot

Correct answer: C

Rationale: The nurse most likely observed plantar warts, which appear on the sole of the foot and are caused by the papillomavirus. Corns (Choice A) and calluses (Choice B) are areas of thickened skin caused by pressure or friction and are not typically associated with viruses. Athlete's foot (Choice D) is a fungal infection that usually affects the skin between the toes and is not caused by a virus like plantar warts.

3. The healthcare provider is caring for a patient who has multiple ticks on lower legs and body. What should the healthcare provider do to rid the patient of ticks?

• A. Use blunt tweezers and pull upward with steady pressure.
• B. Burn the ticks with a match or a small lighter.
• C. Allow the ticks to drop off by themselves.
• D. Apply miconazole and cover with plastic.

Correct answer: A

Rationale: Correct answer: When removing ticks, it is essential to use blunt tweezers to grasp the tick as close to the head as possible and pull upward with even, steady pressure to remove the entire tick. Option B is incorrect because burning ticks can increase the risk of infection and is not recommended. Option C is incorrect as waiting for ticks to drop off by themselves prolongs potential exposure to tick-borne diseases. Option D is incorrect as miconazole is an antifungal medication and not used for tick removal.

4. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose?

• A. Drowsiness, lethargy, and inactivity
• B. Dry mouth, nasal congestion, and blurred vision
• C. Rash, blood dyscrasias, severe depression
• D. Hyperglycemia, weight gain, and edema

Correct answer: C

Rationale: The correct answer is C: Rash, blood dyscrasias, and severe depression are serious side effects of haloperidol that necessitate withholding the dose and prompt further evaluation. Rash can indicate an allergic reaction, blood dyscrasias are serious blood disorders that can be life-threatening, and severe depression may worsen with haloperidol use. Choices A, B, and D are incorrect because drowsiness, lethargy, inactivity, dry mouth, nasal congestion, blurred vision, hyperglycemia, weight gain, and edema are common side effects of haloperidol that may not necessarily contraindicate its use but should be monitored and managed appropriately.

5. To use the nursing process correctly, what must the nurse do first?

• A. Obtain information about the client
• B. Develop a care plan
• C. Implement interventions
• D. Evaluate the client's outcomes

Correct answer: A

Rationale: The first step in the nursing process is to obtain information about the client. This step involves gathering data through assessment to understand the client's needs, health status, and preferences. Developing a care plan (Choice B) comes after the assessment phase. Implementing interventions (Choice C) and evaluating client outcomes (Choice D) occur in subsequent stages of the nursing process. Therefore, the correct initial step is to gather information about the client to form a foundation for providing individualized care.

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