Nursing Elites

1. A client with diabetes mellitus is being taught by a nurse how to perform a capillary blood glucose test. Which of the following instructions should the nurse include in the teaching?

• A. Don sterile gloves after cleansing the site
• B. Puncture the site after cleansing and before the antiseptic dries
• C. Gently wipe the puncture site until a large droplet of blood forms
• D. Hold the finger below the heart level to puncture

Correct answer: B

Rationale: The correct instruction is to puncture the site after cleansing and before the antiseptic dries. This sequence helps ensure proper blood collection without introducing contaminants. Choice A is incorrect because wearing sterile gloves is not necessary for capillary blood glucose testing. Choice C is incorrect as wiping the puncture site can introduce contaminants and alter the blood sample. Choice D is incorrect as holding the finger below the heart level is not required for a capillary blood glucose test.

2. The healthcare provider is caring for a client with a history of hypertension. Which assessment finding would be most concerning?

• A. Blood pressure of 150/90 mmHg
• B. Irregular heart rate
• C. Shortness of breath
• D. Headache

Correct answer: C

Rationale: Shortness of breath in a client with a history of hypertension is a critical assessment finding as it may indicate heart failure, pulmonary edema, or other severe complications. The development of shortness of breath suggests that the client's condition may be rapidly deteriorating and requires immediate medical attention. Elevated blood pressure (150/90 mmHg) is concerning but not as acute as the potential complications associated with shortness of breath. An irregular heart rate and headache can also be symptoms of hypertension, but in this scenario, shortness of breath poses a higher risk of severe cardiovascular or respiratory issues.

3. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment as she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

• A. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care
• B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client
• C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client
• D. Before changing assignments, determine which staff members have fitted particulate filter masks

Correct answer: D

Rationale: The correct course of action for the nurse is to determine which staff members have already been fitted for particulate filter masks before changing assignments. This ensures safety and compliance with infection control protocols. Option A is incorrect as wearing a standard face mask before being fitted for a filter mask does not address compliance with droplet precautions. Option B is incorrect because the priority is to ensure all staff members have appropriate equipment before providing care. Option C is incorrect as a standard mask may not offer sufficient protection when dealing with clients under droplet precautions.

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

• A. "It might help me to listen to music while I'm lying in bed."
• B. "I will use the pain medication as prescribed to manage the pain."
• C. "I will request a different type of pain medication if the pain persists."
• D. "I will ask for a physical therapist to help with the pain."

Correct answer: A

Rationale: The correct answer is A. Listening to music is a non-pharmacological method to help manage mild pain, reflecting an understanding of pain management strategies. It shows the client's grasp of non-pharmacological pain management techniques taught preoperatively. Choice B, while important, only addresses pharmacological pain management, omitting other strategies discussed in preoperative teaching. Choice C jumps to changing medications without considering non-pharmacological methods first, indicating a narrow approach to pain management. Choice D involves a physical therapist, which is not directly related to the pain management strategies typically discussed in preoperative teaching.

5. A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members?

• A. Charge nurse
• B. Registered nurse (RN)
• C. Practical nurse (PN)
• D. Assistive personnel (AP)

Correct answer: B

Rationale: In this scenario, a client who has undergone thoracic surgery and is being admitted from the PACU requires a high level of nursing care. Registered nurses (RNs) have the education and training necessary to provide the complex care and monitoring needed for a post-thoracic surgery client. Charge nurses may oversee units but may not always be directly involved in providing bedside care. Practical nurses (PNs) have a different scope of practice compared to RNs and may not have the advanced skills needed for post-thoracic surgery care. Assistive personnel (AP) provide valuable support but do not have the qualifications to manage the care of a client following thoracic surgery.

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