Nursing Elites

1. When planning to contact the healthcare provider about a client's need for a belt restraint, what information is most important to report?

• A. The presence and location of any pressure ulcers.
• B. Measures already taken to maintain client safety.
• C. Any special mattresses on the client’s bed.
• D. Current vital signs and oxygen saturation.

Correct answer: B

Rationale: The correct answer is B. When reporting to the healthcare provider about a client's need for a belt restraint, it is crucial to provide information on the measures already taken to maintain client safety. This includes detailing alternative strategies that have been tried before considering restraint use. This information helps the healthcare provider assess the situation comprehensively and explore other safety interventions. Choices A, C, and D, though relevant to the client's care, are not as critical to report when discussing the need for a belt restraint. Pressure ulcers (Choice A) are important but not directly related to the need for a belt restraint. The presence of special mattresses (Choice C) may influence overall care but is not the most pertinent information when considering restraints. Current vital signs and oxygen saturation (Choice D) are essential for the client's overall assessment but do not directly address the need for a belt restraint.

2. When designing a plan of care for a client diagnosed with pheochromocytoma, a goal statement should be prepared that relates to which topic?

• A. Psychological counseling to address emotional well-being
• B. Medication teaching concerning adrenergic blockers
• C. Preoperative and postoperative teaching for adrenalectomy
• D. Education on dietary modifications for hypertension

Correct answer: C

Rationale: The correct answer is C: Preoperative and postoperative teaching for adrenalectomy. Pheochromocytoma often requires adrenalectomy as part of the treatment plan. Therefore, educating the client about what to expect before and after the surgery is crucial for optimal care and outcomes. Choices A, B, and D are incorrect. Choice A focuses on emotional well-being rather than the specific surgical intervention needed for pheochromocytoma. Choice B is unrelated as the primary treatment for pheochromocytoma is surgical rather than medication-based. Choice D, though related to managing hypertension, does not address the surgical aspect of treating pheochromocytoma.

3. A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

• A. Ask the most experienced UAP on the team to partner with the newly hired UAP.
• B. Evaluate the newly hired UAP’s level of competency by observing the UAP deliver care.
• C. Review the UAP’s skills checklist and experience with the person who hired the UAP.
• D. Assign the newly hired UAP to clients who require the least complex level of care.

Correct answer: B

Rationale: Evaluating the newly hired UAP’s competency by observing them deliver care is the most effective intervention to ensure they can provide safe and effective care. This approach directly assesses the UAP's actual performance and allows for immediate feedback. Option A, asking the most experienced UAP to partner with the newly hired one, may not guarantee that the new UAP is competent. Option C, reviewing the UAP’s skills checklist and experience with the hiring person, does not provide a direct assessment of the UAP's current abilities. Option D, assigning the new UAP to less complex cases, does not address the need to evaluate their competency directly.

4. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling very tired. Which nursing intervention is most important for the nurse to implement?

• A. Measure vital signs
• B. Auscultate breath sounds
• C. Palpate the abdomen
• D. Observe the skin for bruising

Correct answer: A

Rationale: Discontinuing prednisone abruptly can lead to adrenal insufficiency, which may result in symptoms such as fatigue. Monitoring vital signs is crucial in this situation to assess for potential complications like hypotension, which can be a sign of adrenal insufficiency. Auscultating breath sounds (choice B) is important but not the priority when considering the risk of adrenal insufficiency. Palpating the abdomen (choice C) and observing the skin for bruising (choice D) are not directly related to the potential complications of abruptly stopping prednisone.

5. A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client?

• A. Plain yogurt sweetened with raw honey
• B. Peanuts in the shell, roasted or unroasted
• C. Aged farmer’s cheese with celery sticks
• D. Baked apples topped with dried raisins

Correct answer: A

Rationale: The correct answer is A: Plain yogurt sweetened with raw honey. This option is the best choice for a client with severe neutropenia undergoing chemotherapy because it is less likely to harbor harmful bacteria, which could cause infections due to the weakened immune system. Peanuts in the shell (choice B) may carry a risk of contamination, while aged farmer's cheese with celery sticks (choice C) and baked apples topped with dried raisins (choice D) may not be as safe as plain yogurt for a client with severe neutropenia.

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