Nursing Elites

1. The nurse is developing a plan of care for a client who reports tingling in the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client?

• A. The client will walk 30 minutes three times a week
• B. The client will demonstrate understanding of proper shoe fit
• C. The client will perform foot care daily
• D. The client's blood pressure readings will be less than 160/90 mmHg

Correct answer: D

Rationale: Controlling blood pressure is critical in managing peripheral vascular disease, as elevated pressure can exacerbate vascular damage and complications. While foot care, shoe fit, and exercise are important, lowering blood pressure is a primary goal. Proper blood pressure management helps in preventing further damage to the blood vessels and reduces the risk of complications associated with peripheral vascular disease, making it the most crucial outcome to include in the plan of care for this client.

2. A nurse is caring for a client with a chest tube following lung surgery. What is the most important intervention to ensure the chest tube functions properly?

• A. Clamp the tube if there is excessive drainage
• B. Empty the drainage chamber every 2 hours
• C. Keep the drainage system below chest level
• D. Milk the tube to prevent clots from forming

Correct answer: C

Rationale: The correct answer is C. Keeping the chest tube drainage system below chest level ensures that gravity assists with drainage and prevents fluid or air from flowing back into the pleural space, which could compromise lung function. Clamping the tube if there is excessive drainage (choice A) is incorrect as it can lead to a buildup of pressure and compromise the drainage system. Emptying the drainage chamber every 2 hours (choice B) is important but not as crucial as maintaining the drainage system below chest level. Milking the tube to prevent clots from forming (choice D) is incorrect and could lead to complications such as tube occlusion or damage to the tissue.

3. The nurse instructs a client to use an incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration?

• A. Instruct the client to inhale more deeply
• B. Remind the client to cough after using the spirometer
• C. Praise the client for correct usage
• D. Suggest increasing the frequency of spirometer use

Correct answer: B

Rationale: The correct action for the nurse to take in response to the return demonstration of using an incentive spirometer is to remind the client to cough after using the device. Coughing helps clear secretions from the lungs and promotes lung expansion. Instructing the client to inhale more deeply (Choice A) is not necessary as the primary focus after using the spirometer is to clear secretions. Praising the client for correct usage (Choice C) is positive but does not address the essential step of coughing. Suggesting increasing the frequency of spirometer use (Choice D) is not the immediate action needed after the demonstration.

4. A nurse is working with a new graduate nurse on the delegation of tasks to the unlicensed assistive personnel (UAP). Which task would the new nurse need more teaching about delegating?

• A. Taking a client's blood pressure
• B. Providing oral hygiene for a client
• C. Assessing a client's pain level
• D. Assisting a client with ambulation

Correct answer: C

Rationale: The correct answer is C: Assessing a client's pain level. This task involves clinical judgment and interpretation, which are within the scope of a licensed nurse's practice. Delegating pain assessment to unlicensed personnel could lead to errors in pain management and inappropriate interventions. Choices A, B, and D involve tasks that can be safely delegated to unlicensed assistive personnel as they do not involve interpretation or nursing judgment. Taking a client's blood pressure, providing oral hygiene, and assisting with ambulation are all routine tasks that can be appropriately assigned to UAP under the supervision of a licensed nurse.

5. The client is being taught to choose foods rich in potassium to prevent digitalis toxicity. Which choice indicates the client understands dietary needs?

• A. Three apricots
• B. Medium banana
• C. Naval orange
• D. Baked potato

Correct answer: D

Rationale: The correct answer is D: Baked potato. Baked potatoes are rich in potassium, which is essential in preventing digitalis toxicity by helping to maintain normal electrolyte levels. Apricots, bananas, and oranges are also sources of potassium, but a baked potato has a higher potassium content compared to the other options, making it a more effective choice for preventing digitalis toxicity.

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