Nursing Elites

1. The nurse assesses an older adult who is newly admitted to a long-term care facility. The client has dry, flaky skin and long thickened fingernails. The client has a medical history of a stroke which resulted in left-sided paralysis and dysphagia. In planning care for the client, which task should the nurse delegate to the unlicensed personnel (UAP)?

• A. Soak and file fingernails
• B. Offer fluids frequently
• C. Monitor skin elasticity
• D. Ambulate in the hallway

Correct answer: A

Rationale: Soaking and filing fingernails is a task that can be delegated to UAP. This task does not require specialized nursing skills and can be safely performed by unlicensed personnel. Offering fluids frequently, monitoring skin elasticity, and ambulating require more skilled assessments and interventions, which are responsibilities of the nurse. The client's dry, flaky skin and long thickened fingernails indicate the need for basic hygiene care, making it appropriate for delegation to unlicensed personnel.

2. After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wishes to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply)

• A. Take out dentures and place them in a labeled cup
• B. Apply a body shroud
• C. Place a small pillow under the head
• D. Gently close the eyes

Correct answer: A

Rationale: The correct interventions for the nurse to prepare the body before the family enters the room include taking out dentures and placing them in a labeled cup. This is essential to ensure the dignity of the deceased and maintain their appearance. Applying a body shroud is not typically done before the family views the body, as it may be more appropriate during preparation for transportation to the funeral home. Placing a small pillow under the head and gently closing the eyes are actions that can be comforting but are not essential preparations for the family viewing.

3. After years of struggling with weight management, a middle-aged man is evaluated for gastroplasty. He has experienced difficulty managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Monitor for signs of depression
• B. Apply sequential compression stockings
• C. Provide a wide variety of meal choices
• D. Observe for signs of depression

Correct answer: D

Rationale: Observing for signs of depression is crucial in this patient's plan of care as depression can impact his overall recovery and management post-surgery. Depression is common in individuals struggling with weight management, diabetes mellitus, and hypertension. Monitoring for urinary incontinence (Choice A) is not the priority in this case as the patient is undergoing gastroplasty for weight management, not a urinary issue. Applying sequential compression stockings (Choice B) is important for preventing deep vein thrombosis in immobile patients but is not the priority in this scenario. Providing a wide variety of meal choices (Choice C) is not the most crucial intervention at this stage, as post-gastroplasty dietary restrictions are essential for successful weight management.

4. When designing a plan of care for a client diagnosed with pheochromocytoma, a goal statement should be prepared that relates to which topic?

• A. Psychological counseling to address emotional well-being
• B. Medication teaching concerning adrenergic blockers
• C. Preoperative and postoperative teaching for adrenalectomy
• D. Education on dietary modifications for hypertension

Correct answer: C

Rationale: The correct answer is C: Preoperative and postoperative teaching for adrenalectomy. Pheochromocytoma often requires adrenalectomy as part of the treatment plan. Therefore, educating the client about what to expect before and after the surgery is crucial for optimal care and outcomes. Choices A, B, and D are incorrect. Choice A focuses on emotional well-being rather than the specific surgical intervention needed for pheochromocytoma. Choice B is unrelated as the primary treatment for pheochromocytoma is surgical rather than medication-based. Choice D, though related to managing hypertension, does not address the surgical aspect of treating pheochromocytoma.

5. A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Monitor for signs of activity intolerance
• B. Require visitors to wear respiratory masks
• C. Assess urine and stool for occult blood
• D. Obtain client’s temperature q4 hours

Correct answer: C

Rationale: The correct answer is to assess urine and stool for occult blood. With a low platelet count, there is an increased risk of bleeding. Monitoring for occult blood is essential to detect any signs of internal bleeding. Choices A, B, and D are not the priority interventions in this situation. While monitoring for signs of activity intolerance, requiring visitors to wear respiratory masks, and obtaining the client's temperature are important aspects of care, they are not as critical as assessing for occult blood in a client with a low platelet count.

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