Nursing Elites

1. A client who has just had a mastectomy has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?

• A. Collapsing the device whenever it is 1/2 to 2/3 full of air.
• B. Emptying the device every 4 hours.
• C. Replacing the device every 24 hours.
• D. Keeping the device above the level of the surgical site.

Correct answer: A

Rationale: Collapsing the device when it is 1/2 to 2/3 full of air is the correct nursing action to ensure proper operation of a closed wound suction device (hemovac). This action maintains negative pressure, which is essential for proper suction and drainage of the wound. Emptying the device every 4 hours (Choice B) is not necessary as the focus should be on collapsing it appropriately. Replacing the device every 24 hours (Choice C) is not a standard practice unless indicated by the healthcare provider. Keeping the device above the level of the surgical site (Choice D) is not necessary for the device's proper operation; collapsing it to maintain negative pressure is the key action.

2. Which task can the RN delegate to an unlicensed assistive personnel (UAP)?

• A. Take a history on a newly admitted client
• B. Adjust the rate of a gastric tube feeding
• C. Check the blood pressure of a 2-hour postoperative client
• D. Check on a client receiving chemotherapy

Correct answer: C

Rationale: The correct answer is C. Checking the blood pressure of a 2-hour postoperative client is a task that can be safely delegated to an unlicensed assistive personnel (UAP) as it falls within their scope of practice. This task is routine and does not require specialized nursing knowledge or critical decision-making. Options A, B, and D involve tasks that require a higher level of training and critical thinking beyond the scope of a UAP. Taking a history, adjusting tube feeding rates, and monitoring a client receiving chemotherapy are responsibilities that should be performed by licensed healthcare providers who have the necessary skills and training.

3. A healthcare professional is reviewing a client's fluid and electrolyte status. Which of the following findings should the healthcare professional report to the provider?

• A. BUN 15 mg/dL
• B. Creatinine 0.8 mg/dL
• C. Sodium 143 mEq/L
• D. Potassium 5.4 mEq/L

Correct answer: D

Rationale: The correct answer is D. A potassium level of 5.4 mEq/L is above the expected reference range, indicating hyperkalemia. Hyperkalemia can lead to serious complications such as dysrhythmias, making it important for the healthcare professional to report this finding to the provider for further evaluation and intervention. Choices A, B, and C fall within normal ranges and do not pose an immediate risk to the client's health, so they would not warrant immediate reporting to the provider. Elevated BUN or creatinine levels may indicate kidney dysfunction, while a sodium level of 143 mEq/L falls within the normal range for adults and does not typically require urgent intervention.

4. The nurse is providing discharge instructions to a client who has been prescribed an iron supplement. Which statement by the client indicates a need for further teaching?

• A. I should take the supplement with milk to increase absorption.
• B. I should expect my stools to turn black while taking this supplement.
• C. I should take the supplement with a full glass of water.
• D. I should take the supplement on an empty stomach.

Correct answer: A

Rationale: Taking an iron supplement with milk can decrease its absorption, indicating a need for further teaching.

5. A healthcare professional uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking did the healthcare professional demonstrate?

• A. Confidence
• B. Perseverance
• C. Integrity
• D. Discipline

Correct answer: D

Rationale: The correct answer is 'Discipline.' In this scenario, discipline is exemplified by following a structured and comprehensive assessment process, as seen in the head-to-toe approach. Confidence (choice A) relates to self-assurance and belief in one's abilities, which is not the primary critical thinking demonstrated in this situation. Perseverance (choice B) is the persistence in achieving goals despite challenges, not directly related to the systematic assessment process. Integrity (choice C) pertains to honesty and ethical behavior, which are important traits but not the critical thinking skill exemplified by the structured assessment process shown in the head-to-toe approach.

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