Nursing Elites

1. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?

• A. Assign an RN to supervise a nursing assistant for skin care
• B. Assign a nursing assistant to help the client with self-care activities
• C. Delegate complete care to an unlicensed assistive personnel
• D. Supervise a nursing assistant for skin care

Correct answer: D

Rationale: In this scenario, the best care assignment for the client with a skin tear and hematoma is to supervise a nursing assistant for skin care. This ensures proper wound care while utilizing the skills of the nursing assistant effectively. Assigning an RN to supervise the nursing assistant is appropriate as it provides the necessary expertise for wound care supervision. Delegating complete care to an unlicensed assistive personnel may not be suitable for a client with specific wound care needs. Helping the client with self-care activities may not directly address the urgent need for proper wound care in this situation.

2. A male client with heart failure presents with shortness of breath, audible wheezing, and pink frothy sputum. What action should the nurse take?

• A. Consult with the charge nurse regarding morphine prescription.
• B. Administer the dose of morphine sulfate as prescribed.
• C. Withhold morphine until dyspnea resolves.
• D. Review the need for the prescription with the healthcare provider.

Correct answer: B

Rationale: The correct answer is B: Administer the dose of morphine sulfate as prescribed. In heart failure, morphine helps reduce anxiety, preload, and afterload on the heart, improving oxygenation. The client's symptoms indicate acute decompensated heart failure, and morphine should be administered promptly to relieve distress. Consulting the charge nurse (Choice A) or withholding morphine (Choice C) would delay necessary treatment. Reviewing the prescription with the healthcare provider (Choice D) is not needed in this acute situation.

3. A client with type 2 diabetes mellitus arrives at the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation?

• A. History of hypertension
• B. Fingertips feel numb
• C. Reduced deep tendon reflexes
• D. Elevated fasting blood glucose level

Correct answer: B

Rationale: Numb fingertips may suggest neuropathy, a common complication of diabetes that may indicate a worsening condition. Episodes of weakness and palpitations, combined with neuropathy symptoms, could also suggest hypoglycemia or poor glycemic control, requiring further investigation. The other choices are less likely to be directly related to the client's current symptoms. While a history of hypertension is a common comorbidity in clients with diabetes, it may not directly explain the reported weakness and palpitations. Reduced deep tendon reflexes are more indicative of certain neurological conditions rather than acute emerging situations related to the client's current symptoms. An elevated fasting blood glucose level is expected in a client with type 2 diabetes and may not be the primary indicator of an emerging situation in this context.

4. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which assessment finding indicates that the client's oxygenation is improving?

• A. Pulse oximetry reading of 94%
• B. Heart rate increases from 80 to 90 beats per minute
• C. Respiratory rate increases from 16 to 20 breaths per minute
• D. Client reports increased energy levels

Correct answer: A

Rationale: A pulse oximetry reading of 94% indicates adequate oxygenation. Monitoring oxygen saturation is the most objective way to assess the effectiveness of oxygen therapy. Choices B, C, and D do not directly reflect the client's oxygenation status. An increase in heart rate or respiratory rate may indicate increased work of breathing or stress on the body. The client reporting increased energy levels is subjective and may not directly correlate with improved oxygenation.

5. A client reports that the skin around the edges of a wound is red and swollen. What is the nurse's priority intervention?

• A. Monitor for signs of infection
• B. Reinforce the wound dressing
• C. Contact the healthcare provider
• D. Apply a warm compress to the wound

Correct answer: A

Rationale: The correct answer is to monitor for signs of infection. Redness and swelling around a wound are indicative of a potential infection. The priority intervention for the nurse is to closely monitor the wound for further signs of infection, such as increased drainage or fever. Reinforcing the wound dressing may be necessary, but it is not the priority when infection is suspected. Contacting the healthcare provider is important, but the nurse should first assess and monitor the wound to provide comprehensive information when contacting the provider. Applying a warm compress can potentially worsen the infection by promoting bacterial growth, so it is contraindicated in this situation.

Similar Questions