Nursing Elites

1. The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply)

• A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM)
• B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
• C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
• D. Initiate patient-controlled analgesia (PCA) pumps for two clients immediately postoperative

Correct answer: B

Rationale: The correct answer is B. Obtaining postoperative vital signs for a client one day following unilateral knee arthroplasty is a task within the scope of practice for a practical nurse (PN) and contributes to the client's recovery. Administering insulin (Choice A) involves medication administration, which typically requires a higher level of nursing education. Performing daily surgical dressing changes (Choice C) after an abdominal hysterectomy involves wound care management that is usually beyond the scope of practice for a PN. Initiating patient-controlled analgesia pumps (Choice D) is a complex nursing intervention that requires specialized training and knowledge, exceeding the typical responsibilities of a PN.

2. In what order should the unit manager implement interventions to address the UAP’s behavior after they leave the unit without notifying the staff?

• A. Note date and time of the behavior.
• B. Discuss the issue privately with the UAP.
• C. Plan for scheduled break times.
• D. Evaluate the UAP for signs of improvement.

Correct answer: A

Rationale: The correct order for the unit manager to implement interventions to address the UAP's behavior is to first note the date and time of the behavior. Proper documentation is crucial as it provides a factual record of the incident. This documentation can be used to address the behavior effectively and to track any patterns or improvements in the future. Discussing the issue with the UAP privately (choice B) should come after documenting the behavior. Planning for scheduled break times (choice C) is unrelated to the situation described and does not address the UAP's behavior of leaving without notifying the staff. Evaluating the UAP for signs of improvement (choice D) can only be done effectively after the behavior has been addressed and interventions have been implemented.

3. A high school football player comes to the clinic complaining of severe acne. The mother reports recent behavior changes, including irritability and suspiciousness of friends. The nurse’s assessment reveals an elevated blood pressure. Which intervention should the nurse implement first?

• A. Encourage the client to see a dermatologist
• B. Refer the adolescent to a substance abuse program
• C. Suggest a low-salt, low-fat, and caffeine-free diet
• D. Inquire about a possible use of anabolic steroids

Correct answer: D

Rationale: In this scenario, the high school football player presenting with severe acne, behavior changes, elevated blood pressure, and suspicion of friends suggests the possible use of anabolic steroids. Anabolic steroid use can lead to such symptoms. Therefore, the nurse should first inquire about the possible use of anabolic steroids to address the root cause of the presenting issues. Encouraging the client to see a dermatologist (Choice A) may be necessary but addressing the underlying cause is crucial first. Referring the adolescent to a substance abuse program (Choice B) is premature without confirming steroid use. Suggesting a low-salt, low-fat, and caffeine-free diet (Choice C) is not the priority in this situation where a serious issue like anabolic steroid use needs immediate attention.

4. A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement?

• A. Replace the IV site with a smaller gauge.
• B. Redress the abdominal incision.
• C. Leave the lights on in the room at night.
• D. Apply soft bilateral wrist restraints.

Correct answer: C

Rationale: The correct intervention for a client with dementia who is becoming increasingly confused at night and interfering with dressings and IV lines is to leave the lights on in the room at night. This intervention can help reduce confusion and disorientation. Choice A is incorrect because changing the IV site gauge is not the priority in this situation. Choice B is not necessary unless there are signs of infection or other complications at the abdominal incision site, which are not mentioned in the scenario. Choice D should be avoided as using restraints should be a last resort and is not indicated in this case.

5. A client morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Restrict daily fluid intake to 1500 ml
• B. Weight the client every morning
• C. Maintain accurate intake and output
• D. Administer prescribed diuretic

Correct answer: D

Rationale: Administering a prescribed diuretic is the most important intervention in this scenario as the client is presenting signs of fluid overload and heart failure. Diuretics help reduce fluid retention in the body, alleviating symptoms like edema and crackles. Restricting fluid intake may be necessary in some cases, but in this acute situation, addressing the immediate fluid overload with a diuretic takes precedence. Weighing the client daily and maintaining accurate intake and output are important aspects of monitoring, but they do not directly address the urgent need to manage fluid overload.

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