Nursing Elites

1. A client reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

• A. Closes the door to the client's room
• B. Flushes the client's toilet after emptying the urinary catheter's drainage bag
• C. Measures the client's vital signs routinely
• D. Asks a group of personnel in the hall to speak quietly

Correct answer: B

Rationale: The correct answer is B because flushing the client's toilet after emptying the urinary catheter's drainage bag could disturb the client's rest. The nurse should intervene to ensure a restful environment for the client. Choices A, C, and D are not actions that would be disruptive to the client's sleep. Closing the door to the client's room, measuring vital signs routinely, and asking personnel in the hall to speak quietly are appropriate actions that do not directly disturb the client's rest.

2. A parent of a child who is terminally ill tells a nurse that she wants to take her child home. Which of the following responses should the nurse make?

• A. Your provider will be here later today.
• B. I can give you information on what that would involve.
• C. I understand how you feel. I felt the same way when my sister was terminally ill.
• D. I think you should speak with social services about your request.

Correct answer: B

Rationale: The nurse should offer to explain the process of taking the child home and provide resources for the parent's decision. Choice B is the best response as it shows willingness to support the parent by offering information on what taking the child home would involve. Choices A, C, and D do not directly address the parent's request or provide the necessary information and support needed in this situation.

3. How does a healthcare professional assess a patient's fluid balance, and what signs indicate fluid overload?

• A. Checking lung sounds for crackles
• B. Checking for signs of orthopnea
• C. Monitoring intake and output, and checking for edema
• D. Measuring daily weight

Correct answer: C

Rationale: The correct answer is monitoring intake and output and checking for edema. Monitoring intake and output provides information about fluid balance in the body, while checking for edema helps assess for fluid overload. Lung sounds and signs of orthopnea are more indicative of respiratory issues rather than fluid balance. Daily weight measurement is useful to assess fluid status, but it alone may not provide a comprehensive evaluation of fluid balance.

4. A charge nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

• A. Giving a glycerin suppository to a client for constipation
• B. Evaluating the effectiveness of ibuprofen administered to a client who reported a headache
• C. Discussing dietary changes with a client who has a prescription for a gluten-free diet
• D. Measuring hourly urinary output for a client who is postoperative

Correct answer: D

Rationale: The correct answer is D because measuring hourly urinary output is a task that falls within the scope of practice for assistive personnel. This task involves a technical skill that can be delegated by the charge nurse. Choices A, B, and C require higher-level nursing assessments and interventions that should be performed by licensed nursing staff. Giving a glycerin suppository involves medication administration, evaluating the effectiveness of ibuprofen requires assessment and critical thinking, and discussing dietary changes involves education and assessment of the client's understanding and compliance, all of which are beyond the scope of practice for assistive personnel.

5. The patient has been in bed for several days and needs to be ambulated. What action should the nurse take first?

• A. Dangle the patient at the bedside.
• B. Encourage isometric exercises.
• C. Suggest a high-calcium diet.
• D. Maintain a narrow base of support.

Correct answer: A

Rationale: The correct answer is A: 'Dangle the patient at the bedside.' When a patient has been in bed for an extended period and needs to be ambulated, it is essential to dangle the patient at the bedside first. Dangling involves helping the patient sit on the edge of the bed with their legs over the side before standing up. This action helps prevent orthostatic hypotension, a sudden drop in blood pressure when moving from lying down to standing up, which can lead to dizziness or fainting. Encouraging isometric exercises (choice B) or suggesting a high-calcium diet (choice C) are not the first actions to take before ambulating a patient. Maintaining a narrow base of support (choice D) is related to assisting with ambulation but is not the initial step that should be taken.

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