Nursing Elites

1. A nurse is working with a new graduate nurse on the delegation of tasks to the unlicensed assistive personnel (UAP). Which task would the new nurse need more teaching about delegating?

• A. Taking a client's blood pressure
• B. Providing oral hygiene for a client
• C. Assessing a client's pain level
• D. Assisting a client with ambulation

Correct answer: C

Rationale: The correct answer is C: Assessing a client's pain level. This task involves clinical judgment and interpretation, which are within the scope of a licensed nurse's practice. Delegating pain assessment to unlicensed personnel could lead to errors in pain management and inappropriate interventions. Choices A, B, and D involve tasks that can be safely delegated to unlicensed assistive personnel as they do not involve interpretation or nursing judgment. Taking a client's blood pressure, providing oral hygiene, and assisting with ambulation are all routine tasks that can be appropriately assigned to UAP under the supervision of a licensed nurse.

2. A client presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge. Which action should the nurse take first?

• A. Notify the healthcare provider immediately
• B. Begin continuous fetal monitoring
• C. Check the amniotic fluid pH
• D. Assess maternal vital signs

Correct answer: B

Rationale: Greenish-brown discharge likely indicates meconium in the amniotic fluid, which poses a risk to the fetus. Continuous fetal monitoring should be initiated immediately to assess for signs of fetal distress. Meconium-stained amniotic fluid can lead to meconium aspiration syndrome in the newborn, so timely monitoring is crucial. Checking the amniotic fluid pH can help confirm the presence of meconium but is not the priority over fetal monitoring. Assessing maternal vital signs is important but secondary to monitoring the fetal well-being in this urgent situation. Notifying the healthcare provider can follow once the immediate fetal assessment is underway.

3. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse?

• A. Relieve the nurse performing CPR
• B. Go get the code cart
• C. Participate with the compressions or breathing
• D. Validate the client's advanced directive

Correct answer: C

Rationale: The correct answer is C. The second nurse should assist with compressions or breathing to ensure the patient receives adequate care during CPR. This immediate intervention is crucial in maintaining blood circulation and oxygenation to vital organs. Choice A is incorrect because simply relieving the nurse performing CPR may lead to a delay in essential life-saving measures. Choice B is incorrect as the primary focus should be on providing direct assistance rather than fetching equipment. Choice D is incorrect as validating the client's advanced directive is not the priority in this emergency situation.

4. A client is recovering from a hip replacement surgery. What is the priority nursing intervention to prevent complications?

• A. Encourage bed rest to prevent strain on the hip
• B. Assist the client with early ambulation
• C. Provide continuous passive motion therapy
• D. Administer pain medication before activity

Correct answer: B

Rationale: The correct answer is B: Assist the client with early ambulation. Early ambulation is a key intervention to prevent complications like deep vein thrombosis (DVT) and promote circulation after hip replacement surgery. It also helps with overall recovery and reduces the risk of complications related to immobility, such as muscle atrophy and pressure ulcers. Choice A is incorrect as bed rest should be avoided to prevent complications associated with immobility. Choice C, continuous passive motion therapy, is not the priority intervention immediately post-hip replacement surgery. Choice D, administering pain medication before activity, is important but not the priority intervention to prevent complications in this case.

5. A client with multiple sclerosis is admitted with an acute exacerbation. What is the nurse's priority action?

• A. Monitor the client’s vital signs every hour.
• B. Assess for changes in the client’s muscle strength.
• C. Administer prescribed corticosteroids to reduce inflammation.
• D. Educate the client on managing fatigue and preventing relapses.

Correct answer: C

Rationale: The correct answer is C. Administering prescribed corticosteroids to reduce inflammation is the priority action when a client with multiple sclerosis is admitted with an acute exacerbation. Corticosteroids help manage symptoms during exacerbations and reduce inflammation. Monitoring vital signs and assessing muscle strength are important aspects of care but not the priority during an acute exacerbation. Educating the client on managing fatigue and preventing relapses is essential but can be addressed after the acute exacerbation has been managed.

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