Nursing Elites

1. A client scheduled for a left mastectomy and axillary lymph node dissection is wearing a wedding band on her left ring finger. The nurse should take which action?

• A. Tape the wedding band in place
• B. Ask the client to sign a release freeing the hospital of responsibility if the wedding band is lost during surgery
• C. Explain to the client why the wedding band must be removed
• D. Ask the client whether she would like to remove the wedding band or wear it to surgery

Correct answer: C

Rationale: In most situations, a wedding band may be taped in place and worn during a surgical procedure. However, if there is a possibility that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a healthcare facility, the client is usually asked to sign a form that releases the agency from responsibility if a client's valuables are lost. After a mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which can result in swelling of the arm and hand on the affected side. Therefore, the appropriate nursing action is to ask the client to remove the wedding band and explain why. This ensures the client's safety and prevents potential complications. Option A is incorrect because taping the wedding band may not be sufficient if swelling occurs. Option B is incorrect as it does not address the immediate need to remove the wedding band. Option D is incorrect because it fails to provide the client with the necessary information about the potential risks of wearing the wedding band during surgery.

2. Which of the following statements to the client's family would be appropriate when preparing to provide postmortem care to the client?

• A. "You will not be allowed to see your family member after the postmortem care is performed."?
• B. "I am not able to assist you, but we can call pastoral care if you need any comfort."?
• C. "Unfortunately, we are not allowed to incorporate any cultural practices in my preparations."?
• D. "I will be ensuring that your family member is properly identified before they are transported."?

Correct answer: D

Rationale: The correct statement when preparing to provide postmortem care to the client's family is to assure them that the family member will be properly identified before transportation. This is crucial in ensuring the correct individual is being handled respectfully. Choices A, B, and C are incorrect as they do not address the essential aspect of ensuring the proper identification of the deceased before transportation. It is important to allow the family to see their loved one after postmortem care and, if possible, incorporate any cultural practices. Providing comfort and support to the family during this difficult time is also essential in delivering holistic care.

3. The advanced directive in a client's chart is dated August 12, 1998. The client's daughter produces a Power of Attorney for Health Care, dated 2003, which contains different care directions. What should the nurse do?

• A. Follow the 1998 version because it's part of the legal chart.
• B. Follow the 1998 version because the physician's code order is based on it.
• C. Follow the 2003 version, place it in the chart, and communicate the update appropriately.
• D. Follow neither until clarified by the unit manager.

Correct answer: C

Rationale: The document dated 2003 supersedes the previous version and should be used as a basis for care directions. The nurse should follow the 2003 version, place it in the chart, and communicate the update appropriately to ensure that the most current care directions are followed. Choices A and B are incorrect because the 1998 version is now outdated, and the nurse should not rely on it for care decisions. Choice D is incorrect because the nurse should not delay following the updated document, and seeking clarification from the unit manager can lead to avoidable delays in care.

4. When the healthcare provider is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client?

• A. corner of the mouth to tragus of the ear
• B. corner of the eye to top of the ear
• C. tip of the chin to the sternum
• D. tip of the nose to the earlobe

Correct answer: D

Rationale: A nasopharyngeal airway is measured from the tip of the nose to the earlobe. This measurement ensures that the airway is of the correct length to reach the nasopharynx without being too long or too short. Choices A, B, and C are incorrect as they do not provide the appropriate measurement for selecting the correct size of a nasopharyngeal airway. The distance from the corner of the mouth to the tragus of the ear (Choice A) is used to measure for an oropharyngeal airway, not a nasopharyngeal airway. Similarly, the other choices (B and C) do not correlate with the correct measurement of a nasopharyngeal airway.

5. A nurse is planning task assignments for the day. Which task should the nurse assign to the nursing assistant?

• A. Suctioning a client who requires periodic suctioning
• B. Assessing a client who has undergone an arteriogram and requires close monitoring
• C. Performing colostomy irrigation on a client with an ostomy
• D. Assisting a client who needs frequent ambulation with a walker

Correct answer: D

Rationale: When delegating tasks, a nurse must consider the staff member's education and competency level. Noninvasive tasks like helping a client ambulate with a walker are usually suitable for nursing assistants. Suctioning a client and colostomy irrigation are invasive procedures that require a licensed nurse's skills. Assessing a client post-arteriogram for any complications or changes in condition also necessitates the expertise of a licensed nurse. Therefore, the most appropriate task to assign to a nursing assistant is assisting a client who needs frequent ambulation with a walker.

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