Nursing Elites

1. A nurse is planning care for a client who had a stroke. What task should be assigned to the assistive personnel?

• A. Assist the client with a partial bed bath
• B. Measure the client’s blood pressure after the nurse administers antihypertensive medications
• C. Use a communication board to ask what the client wants for lunch
• D. Feed the client

Correct answer: A

Rationale: The correct answer is to assign the assistive personnel to assist the client with a partial bed bath. This task falls within the scope of practice for assistive personnel and is a common activity in caring for clients who have had a stroke. Choice B involves measuring blood pressure, which should be done by a licensed nurse. Choice C requires the use of a communication board, which can be done by any healthcare team member, not just assistive personnel. Choice D involves feeding the client, which may require assessment and intervention by a licensed nurse to ensure proper nutrition and safety.

2. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

• A. ''I think I should take my pain medication more often since it is not controlling my pain.''
• B. ''Breathing faster will help me keep my mind off of the pain.''
• C. ''It might help me to listen to music while I'm lying in bed.''
• D. ''I don't want to walk today because I have some pain.''

Correct answer: C

Rationale: The correct answer is C because listening to music is an effective nonpharmacological intervention for managing mild pain. Choice A is incorrect as increasing the frequency of pain medication without consulting healthcare providers can lead to adverse effects. Choice B is incorrect as distracting techniques like breathing faster may not address the pain effectively. Choice D is incorrect as avoidance of physical activity due to pain can hinder postoperative recovery.

3. A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.)

• A. “The temperature around the IV site is cooler.”
• B. “The rate of the infusion increases.”
• C. “The skin at the IV site is red.”
• D. “The IV dressing is damp.”

Correct answer: A

Rationale: The correct statement is: 'The temperature around the IV site is cooler.' Cooler temperature around the site is indicative of infiltration, where IV fluid leaks into the surrounding tissue, causing tissue swelling. The other options are incorrect: B) An increase in infusion rate is not a sign of infiltration; instead, it could indicate an issue with the infusion pump or the IV catheter. C) Redness around the IV site is more indicative of infection rather than infiltration. D) A damp IV dressing is more suggestive of a leak in the IV system, not infiltration.

4. A client who is post-op following a partial colectomy has an NG tube set on low continuous suction. The client complains of a sore throat and asks when the NG tube will be removed. Which response by the nurse is appropriate at this time?

• A. When the GI tract is working again, in about three to five days, the tube can be removed.
• B. The tube will be removed once your nausea improves.
• C. You can expect the tube to be removed in about a week.
• D. The tube will be removed once the drainage stops.

Correct answer: A

Rationale: The correct response is A: 'When the GI tract is working again, in about three to five days, the tube can be removed.' After a partial colectomy, the GI tract needs time to recover and start functioning properly. The NG tube is typically removed when peristalsis returns, indicating GI function restoration, which usually occurs within 3-5 days post-op. Choice B is incorrect because the removal of the NG tube is not solely based on nausea improvement. Choice C is incorrect as it provides a longer duration for tube removal than is usually necessary. Choice D is incorrect as the cessation of drainage alone does not dictate NG tube removal; the return of GI function is the primary indicator.

5. A nurse is providing care to a 17-year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?

• A. Abnormal breath sounds
• B. Cyanosis of the lips
• C. Increasing pulse rate
• D. Pulse oximeter reading of 92%

Correct answer: C

Rationale: An increasing pulse rate can be an early sign of poor oxygenation as the body tries to compensate. Abnormal breath sounds (choice A) can indicate respiratory issues, but they may not always be an early sign of poor oxygenation. Cyanosis of the lips (choice B) is a late sign of inadequate oxygenation. A pulse oximeter reading of 92% (choice D) indicates mild hypoxemia but may not be considered an early indication of poor oxygenation.

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