Nursing Elites

1. The client is being taught how to use a peak flow meter. The nurse explains that this device should be used to:

• A. Determine oxygen saturation
• B. Measure forced expiratory volume
• C. Monitor the atmosphere for the presence of allergens
• D. Provide metered doses for inhaled bronchodilator

Correct answer: B

Rationale: A peak flow meter is used to measure forced expiratory volume, which helps in monitoring asthma. This measurement provides valuable information about how well the client's lungs are functioning and how narrow their airways are. Choice A is incorrect because determining oxygen saturation is typically done using a pulse oximeter. Choice C is incorrect as a peak flow meter is not used to monitor the atmosphere for allergens but rather to assess lung function. Choice D is incorrect as providing metered doses for inhaled bronchodilators is the function of a metered-dose inhaler, not a peak flow meter.

2. A charge nurse is assigning tasks to a nurse and assistive personnel for a group of clients. Which of the following tasks should the charge nurse delegate to the AP?

• A. Report ABG results to the provider
• B. Instruct a client about how to use an incentive spirometer
• C. Administer an enteral feeding to a client who has an established gastrostomy tube
• D. Monitor the color of a client’s urinary output

Correct answer: D

Rationale: The correct answer is D because monitoring the color of a client's urinary output is a task that can be safely delegated to assistive personnel. This task involves basic observation and does not require specialized nursing knowledge or skills. Choice A is incorrect because reporting ABG results to the provider requires interpretation and critical thinking skills typically performed by a nurse. Choice B is incorrect as instructing a client about how to use an incentive spirometer involves educating and assessing the client, which is a nursing responsibility. Choice C is incorrect as administering enteral feeding to a client with a gastrostomy tube requires nursing expertise to ensure proper technique and monitoring for complications.

3. When taking a history of a 3-year-old with neuroblastoma, what comment by the parents requires follow-up and is consistent with the diagnosis?

• A. The child has been listless and has lost weight.
• B. The urine is dark yellow and in small amounts.
• C. Clothes are becoming tighter across her abdomen.
• D. We notice muscle weakness and some unsteadiness.

Correct answer: C

Rationale: The correct answer is C. Clothes becoming tighter across the abdomen is indicative of an abdominal mass, a common presentation in neuroblastoma. This symptom should be followed up on further as it aligns with the diagnosis. Choices A, B, and D are less specific to neuroblastoma. Weight loss and listlessness (Choice A) can be nonspecific symptoms, while dark yellow urine in small amounts (Choice B) may suggest dehydration or other conditions. Muscle weakness and unsteadiness (Choice D) could point towards various neurological or muscular issues but are not as directly related to neuroblastoma as the symptom described in Choice C.

4. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?

• A. Remove clocks from the client’s room
• B. Use full-length side rails on the client’s bed
• C. Check on the client frequently while they are in the restroom
• D. Encourage physical activity throughout the day to expend energy

Correct answer: D

Rationale: Encouraging physical activity throughout the day is an effective way to manage confusion in clients and reduce the need for restraints. Physical activity helps in expending energy, promoting circulation, and improving overall well-being. Removing clocks from the client’s room (choice A) may not directly address the issue of confusion or reduce the need for restraints. Using full-length side rails on the client’s bed (choice B) can actually increase the risk of entrapment and should be avoided. Checking on the client frequently while they are in the restroom (choice C) is important for monitoring safety but may not directly address the underlying issue of confusion and the need for restraints.

5. Which patient will lead the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan?

• A. A patient who is completely immobile
• B. A patient who is not completely immobile
• C. A patient at risk for single-system involvement
• D. A patient who is at risk for multisystem problems

Correct answer: B

Rationale: The correct answer is B because the nursing diagnosis of Impaired physical mobility is appropriate for a patient who has some limitations in mobility but is not completely immobile. Choice A is incorrect as a patient who is completely immobile would not have impaired physical mobility but rather no physical mobility at all. Choices C and D are also incorrect as they do not directly relate to the defining characteristics of Impaired physical mobility, which involve limitations in movement and physical activity.

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