Nursing Elites

1. In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:

• A. diabetic signs and symptoms.
• B. nutritional status.
• C. bleeding problems.
• D. availability of insulin.

Correct answer: C

Rationale: In a disaster situation, when assessing a diabetic client on insulin, the nurse should assess for diabetic signs and symptoms to monitor the client's condition, nutritional status to ensure proper dietary management, and availability of insulin to maintain the client's medication regimen. Bleeding problems are not directly related to diabetes or insulin use, making it the exception in this assessment scenario. Therefore, bleeding problems would not be a typical focus of assessment in this context.

2. A client asks a nurse about the procedure for becoming an organ donor. The nurse provides the client with which information?

• A. To speak with the chaplain about the psychosocial aspects of becoming a donor
• B. That this decision must be made by the next of kin at the time of the client's death
• C. That anatomic gifts must be made in writing and signed by the client
• D. To let the health care provider know about the request so that it may be documented in the client's record

Correct answer: C

Rationale: When a person wishes to become an organ donor, they need to understand that anatomic gifts must be made in writing and signed by the individual. The gift must be made by the donor themselves, typically an individual who is at least 18 years old. If the client is unable to sign, the document should be signed by another person and two witnesses. While speaking to a chaplain or informing the healthcare provider may be part of the process, the essential step is to have a written document signed by the client. Choice A is incorrect as it does not address the procedural aspect of becoming an organ donor. Choice B is incorrect as the decision to make an anatomic gift is typically made by the individual themselves, not the next of kin. Choice D is incorrect as simply informing the healthcare provider is not sufficient for the procedure of becoming an organ donor; a written and signed document by the client is necessary.

3. A nurse is planning client assignments for the day. Which task should the nurse assign to the nursing assistant (unlicensed assistive personnel)?

• A. Recording the urinary output for a client with renal calculi whose urine must be strained
• B. Dressing change instructions for a client who had a mastectomy 2 days ago
• C. Reporting abnormal lab values to the health care provider for a client scheduled for a laparoscopic cholecystectomy
• D. Preprocedural teaching for a client scheduled for a cardiac stress test

Correct answer: A

Rationale: The nurse is legally responsible for client assignments and must assign tasks based on state nursing practice act guidelines and job descriptions provided by the employing agency. The nursing assistant is trained to measure, collect, and strain urine, making recording urinary output for a client with renal calculi a suitable task for the nursing assistant. This task falls within the nursing assistant's role description. Dressing change instructions for a client who had a mastectomy involve a higher level of skill and knowledge, beyond the scope of a nursing assistant. Reporting abnormal lab values to the health care provider for a client scheduled for a laparoscopic cholecystectomy requires interpretation and clinical judgment, which is typically not within the nursing assistant's role. Preprocedural teaching for a client scheduled for a cardiac stress test involves providing detailed information and education, which is usually the responsibility of a licensed nurse or other qualified healthcare provider.

4. Upon first meeting, a new nurse manager makes eye contact, smiles, initiates conversation about the previous work experience of nurses, and encourages active participation by nurses in the dialogue. Her behavior is an example of:

• A. Aggressiveness.
• B. Passive aggressiveness.
• C. Passiveness.
• D. Assertiveness.

Correct answer: D

Rationale: The correct answer is 'Assertiveness.' This nurse manager is demonstrating assertive behavior by confidently engaging with the nurses, showing interest in their work experience, and encouraging active participation. Aggressive behavior is forceful and dominating, while passive behavior is submissive and timid. Passive-aggressive behavior involves indirect manipulation or control, which is not demonstrated in this scenario.

5. A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?

• A. calcium
• B. magnesium
• C. potassium
• D. sodium chloride

Correct answer: D

Rationale: When a client with an ileus is placed on intestinal tube suction, the primary electrolyte lost is sodium chloride. Duodenal intestinal fluid contains potassium (K+), sodium (Na+), and bicarbonate. Suctioning is done to remove excess fluids, leading to a decrease in the client's sodium chloride levels. Therefore, options A, B, and C are incorrect as calcium, magnesium, and potassium are not the primary electrolytes lost during intestinal suction in a client with an ileus.

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