Nursing Elites

1. The nurse assigns a UAP to assist with the personal care of a client experiencing an acute exacerbation of multiple sclerosis. Which instruction should the nurse provide the UAP?

• A. Assist the client with a hot bath
• B. Encourage self-care but allow rest periods
• C. Face the client directly when speaking
• D. Keep the head of the bed elevated at all times

Correct answer: B

Rationale: The correct instruction for the UAP to provide when assisting a client experiencing an acute exacerbation of multiple sclerosis is to encourage self-care but allow rest periods. Clients with multiple sclerosis often experience fatigue, so promoting self-care activities while ensuring they have adequate rest periods is crucial for symptom management and maintaining independence. Choice A is incorrect as hot baths can potentially exacerbate symptoms in clients with multiple sclerosis. Choice C is unrelated to the client's care needs during an acute exacerbation of multiple sclerosis. Choice D is not a priority instruction in this situation and may not directly impact the client's immediate care needs.

2. During a routine prenatal visit at the antepartal clinic, a multipara at 35-weeks gestation presents with 2+ edema of the ankles and feet. Which additional information should the PN report to the RN?

• A. Due date
• B. Blood pressure
• C. Gravida and parity
• D. Fundal height

Correct answer: B

Rationale: Blood pressure is the most critical information to report to the RN in this scenario. The presence of edema, along with high blood pressure, can be indicative of preeclampsia, a severe condition in pregnancy. Monitoring blood pressure is essential for assessing the patient's condition and taking appropriate actions if necessary. Choices A, C, and D are not as urgent in this situation. The due date, gravida, and parity are important for overall assessment but do not address the immediate concern of potential preeclampsia. Fundal height is used to assess fetal growth and position but is not the priority when edema and high blood pressure are present.

3. A client who is receiving chemotherapy has developed stomatitis. Which instruction should the nurse provide the UAP who is assisting with the care of this client?

• A. Keep the room environment free of unpleasant odors
• B. Gather supplies for protective environmental precautions
• C. Assist the client with feeding at meal times
• D. Provide gentle and meticulous mouth care

Correct answer: D

Rationale: Providing gentle and meticulous mouth care is critical for a client with stomatitis as it helps prevent further irritation and infection of the mucous membranes. Keeping the room environment free of unpleasant odors (Choice A) is important for the client's comfort but not directly related to managing stomatitis. Gathering supplies for protective environmental precautions (Choice B) is not relevant to addressing stomatitis. Assisting the client with feeding at meal times (Choice C) is important for overall care but does not specifically target the care needed for stomatitis.

4. A registered nurse is preparing to hang the first bag of total parenteral nutrition (TPN) solution. The client has a central line, and this is the first bag he will receive. Which of the following is the most essential piece of equipment to obtain prior to hanging the bag?

• A. Blood glucose meter
• B. Noninvasive blood pressure monitor
• C. Electronic infusion pump
• D. Urine test strips

Correct answer: C

Rationale: An electronic infusion pump is essential for administering TPN to ensure accurate delivery and avoid complications such as fluid overload or improper nutrient delivery. The pump helps regulate the flow rate precisely, which is crucial when infusing TPN. Monitoring the client's blood glucose is important but not immediately necessary before hanging the TPN bag. A noninvasive blood pressure monitor is not directly related to administering TPN and is not the most essential equipment needed for this procedure. Urine test strips are not required for administering TPN via a central line and are not essential equipment for this specific task.

5. What is a priority when providing care for a patient with a newly inserted tracheostomy?

• A. Keeping the tracheostomy tube clean and dry
• B. Providing regular oral hygiene
• C. Monitoring for signs of infection and ensuring a patent airway
• D. Encouraging the patient to cough and deep breathe

Correct answer: C

Rationale: When caring for a patient with a newly inserted tracheostomy, the priority is to monitor for signs of infection and ensure a patent airway. This is crucial to prevent complications such as airway obstruction or infection. While keeping the tracheostomy tube clean and dry is important for overall care, it is not the highest priority when compared to ensuring a patent airway. Providing regular oral hygiene is essential for the patient's comfort but takes a secondary role to maintaining airway patency. Encouraging the patient to cough and deep breathe may be beneficial but is not as critical as monitoring for infection and keeping the airway clear.

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