Nursing Elites

1. When caring for a patient diagnosed with diabetes mellitus and circulatory insufficiency, experiencing peripheral neuropathy and urinary incontinence, on which areas does the nurse focus care?

• A. Decreased pain sensation and increased risk of skin impairment
• B. Decreased caloric intake and accelerated wound healing
• C. High risk for skin infection and low saliva pH level
• D. High risk for impaired venous return and dementia

Correct answer: A

Rationale: The nurse should focus on decreased pain sensation and increased risk of skin impairment due to the patient's conditions. Peripheral neuropathy can lead to decreased pain sensation, making the patient more prone to injuries without realizing it. Additionally, the combination of circulatory insufficiency, peripheral neuropathy, and urinary incontinence can increase the risk of skin breakdown and impaired healing. Choices B, C, and D are incorrect because they do not address the specific issues related to the patient's diagnoses and symptoms.

2. The nurse is caring for an adult who has fluid volume excess. When weighing the client, the nurse should:

• A. Weigh the client upon rising
• B. Weigh the client at different times of the day
• C. Weigh the client after meals
• D. Weigh the client weekly

Correct answer: A

Rationale: Weighing the client upon rising is the correct approach when caring for a client with fluid volume excess. Weighing the client in the morning upon rising provides a consistent and accurate measure of weight, as it helps to eliminate the influence of daily fluctuations that can occur throughout the day. Weighing at different times of the day (choice B) may lead to inconsistent measurements due to variations in food intake, hydration status, and other factors. Weighing the client after meals (choice C) can also lead to inaccurate readings as food and fluid intake can affect weight. Weighing the client weekly (choice D) is not frequent enough to monitor changes in weight accurately for a client with fluid volume excess.

3. When lifting a bedside cabinet to move it closer to a client who is sitting in a chair, which of the following actions should the nurse take to prevent self-injury?

• A. Bend at the waist
• B. Keep feet close together
• C. Use back muscles for lifting
• D. Stand close to the cabinet when lifting it

Correct answer: D

Rationale: The correct answer is to stand close to the cabinet when lifting it. This action keeps the object close to the nurse's center of gravity, reducing the risk of back strain. Bending at the waist (Choice A) can increase the risk of back injury as it puts strain on the lower back. Keeping feet close together (Choice B) does not provide a stable base of support for lifting a heavy object. Using back muscles for lifting (Choice C) is incorrect as it can lead to back strain and injury. Therefore, standing close to the cabinet when lifting it is the safest and most effective approach to prevent self-injury.

4. A client requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

• A. Help the client take sips of water to promote insertion of the NG tube.
• B. Insert the tube without asking the client to swallow.
• C. Advance the tube continuously without pausing.
• D. Use a large-bore tube for insertion.

Correct answer: A

Rationale: The correct action when inserting an NG tube is to help the client take sips of water. This helps facilitate the insertion of the tube by promoting swallowing and passage through the esophagus. Asking the client to swallow assists in guiding the tube into the stomach. Inserting the tube without asking the client to swallow may lead to incorrect placement or discomfort. Advancing the tube continuously without pausing can cause the tube to coil in the esophagus, leading to complications. Using a large-bore tube for insertion is unnecessary and may increase the risk of injury or discomfort for the client.

5. A healthcare provider is delegating client care to assistive personnel. Which of the following tasks should the healthcare provider delegate?

• A. Evaluating healing of an incision
• B. Inserting an NG Tube
• C. Performing a simple dressing change
• D. Changing IV tubing

Correct answer: C

Rationale: The correct task that a healthcare provider should delegate to assistive personnel is performing a simple dressing change. Assistive personnel are trained and competent in performing basic wound care activities like simple dressing changes. Evaluating the healing of an incision requires clinical judgment and assessment skills that are typically performed by licensed healthcare professionals, such as nurses or physicians. Inserting an NG tube and changing IV tubing involve invasive procedures that require specialized training and skills, making them tasks that should be performed by licensed healthcare providers rather than assistive personnel.

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