Nursing Elites

1. During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?

• A. 40-year-old with chronic pancreatitis who has gnawing abdominal pain
• B. 58-year-old who has compensated cirrhosis and is complaining of anorexia
• C.
• D. 36-year-old recovering from a laparoscopic cholecystectomy who has severe shoulder pain

Correct answer: C

Rationale:

2. For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?

• A. Assessing the patient for jaundice
• B. Providing oral hygiene after a meal
• C. Palpating the abdomen for distention
• D. Assisting the patient to choose the diet

Correct answer: B

Rationale: Providing oral hygiene after a meal is an appropriate task to delegate to unlicensed assistive personnel (UAP) as it falls within their scope of practice. UAP can assist with basic personal care activities like oral hygiene. Assessing the patient for jaundice and palpating the abdomen for distention involve making clinical assessments that require a higher level of education and training, typically performed by licensed practical/vocational nurses (LPNs/LVNs) or registered nurses (RNs). Assisting the patient to choose the diet also requires specialized knowledge and would be more appropriate for a nurse to address, considering the complexity of dietary requirements in cirrhosis.

3. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around their neck. Which action by the nurse is appropriate?

• A. Ask the patient about the item and its significance.
• B. Ask the patient to lock the item with other valuables in the hospital's safe.
• C. Tell the patient that a family member should take valuables home.
• D. No action is necessary.

Correct answer: A

Rationale: The small charm tied to a leather strip is likely an amulet, which many cultures consider an important means of protection from 'evil spirits.' When a patient appears to have a health practice the nurse is unfamiliar with, the nurse should ask for clarification in a non-judgmental way that communicates acceptance of their beliefs and allows for open communication. Thus, the nurse in this situation should inquire about the amulet's meaning to the patient. Asking the patient to lock the item with other valuables in the hospital's safe, telling the patient that a family member should take valuables home, or doing nothing does not address the importance or meaning of a cultural health practice to the patient and does not allow the nurse to gain an understanding of the patient's cultural health practices.

4. You are taking care of 7 patients today. One of your residents wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care task is the lowest in terms of priority?

• A. The water
• B. Help to the bathroom
• C. The chest pain
• D. The crying person

Correct answer: D

Rationale: The lowest priority patient care task in this scenario is addressing the emotional need of the patient who is crying because his daughter did not visit him today. While emotional support is important, the other needs - providing water, assisting to the bathroom, and addressing chest pain - are physical needs that must take priority as they directly impact the patient's well-being and health. It is crucial to acknowledge and address emotional needs but in this situation, the physical needs of the patients should be addressed first.

5. What is the first aid for frostbite?

• A. Running cold water over the affected area. Warm or hot water will shock the area and cause more tissue damage.
• B. Run warm water over the area to rapidly rewarm the affected area.
• C. Run hot water over the area to warm the area as quickly as possible.
• D. Cover the area with a blanket, using a heating pad if the blanket isn't warm enough.

Correct answer: A

Rationale: First aid for frostbite involves running cold water over the affected area. It is important to avoid warm or hot water as it can shock the area and cause further tissue damage. Warm water should not be used to rapidly rewarm the affected area. Similarly, hot water should also be avoided as it can warm the area too quickly and potentially cause harm. Covering the area with a blanket and using a heating pad may not be effective and can even lead to more damage. Seeking medical assistance is crucial if the tissue appears necrotic to prevent further complications.

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