Nursing Elites

1. The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?

• A. Document the seizure
• B. Perform neurologic checks
• C. Take the patient's vital signs
• D. Restrain the patient for protection

Correct answer: C

Rationale: After a patient with migraine headaches has a seizure, it is important to assess their vital signs to monitor their condition. This task can be safely delegated to a nursing assistant as it falls within their scope of practice. Documenting the seizure and performing neurologic checks require a higher level of training and should be done by a nurse or healthcare provider. Restraint should never be used as a first-line intervention after a seizure unless there is an immediate threat to the patient's safety, and it should be done following proper protocols and with appropriate training.

2. An experienced healthcare professional instructs a new colleague on caring for a patient with dyspnea due to a pulmonary fungal infection. Which action by the new colleague indicates a need for further teaching?

• A. Listening to the patient's lung sounds several times during the shift
• B. Placing the patient in droplet precautions and in a private hospital room
• C. Increasing the oxygen flow rate to maintain oxygen saturation above 90%
• D. Monitoring the patient's serology results to identify the specific infecting organism

Correct answer: B

Rationale: The correct answer is placing the patient in droplet precautions and in a private hospital room. Fungal infections are not transmitted from person to person, so isolation procedures like droplet precautions are unnecessary. Listening to the patient's lung sounds, increasing the oxygen flow rate, and monitoring serology results are all appropriate actions in caring for a patient with dyspnea caused by a pulmonary fungal infection.

3. You have measured the urinary output of your resident at the end of your 8-hour shift. The output is 25 ounces. What should you do next?

• A. Convert the number of ounces into cc.
• B. Convert the number of ounces into cm.
• C. Immediately report this poor output to the nurse.
• D. Know that 25 ounces of urine is too much in 8 hours.

Correct answer: A

Rationale: You should convert the number of ounces into cc because cc is the unit of measurement used to record intake and output accurately. This urinary output falls within normal limits, so there is no need to report it immediately to the nurse. It is essential to report urinary outputs of less than 30 cc per hour to detect potential issues early. Converting ounces into centimeters (cm) is not appropriate in this context as cm is a unit of length, not volume. Knowing that 25 ounces of urine is too much in 8 hours is inaccurate as it depends on various factors like fluid intake and individual differences.

4. Penny Thornton has had a stroke, or CVA, and is having difficulty eating on her own. Soon, she will be getting some assistive devices for eating meals. Which healthcare worker will be providing Penny with these assistive devices?

• A. A physical therapist
• B. A speech therapist
• C. A social worker
• D. An occupational therapist

Correct answer: D

Rationale: An occupational therapist is the healthcare professional responsible for assessing the needs of individuals, like Penny, regarding assistive devices that aid them in their daily activities. In this case, assistive devices for eating, such as weighted plates and specialized utensils, are crucial for helping Penny regain independence in feeding herself. Physical therapists focus more on mobility and movement, speech therapists on communication and swallowing disorders, and social workers on providing emotional and social support. Therefore, the correct choice is the occupational therapist as they specialize in activities of daily living and promoting independence.

5. A client is receiving high-dose brachytherapy as a form of cancer treatment. What type of teaching must the nurse include when educating this client about safety?

• A. The client must remain in isolation under airborne precautions
• B. The client should stay in a private room at the hospital
• C. The client may need to limit visits from friends and family
• D. Both B and C

Correct answer: D

Rationale: A client undergoing high-dose brachytherapy has a radiation implant placed for cancer treatment. To ensure safety, the client should be in a private hospital room to prevent radiation exposure to others. Limiting visits from friends and family is necessary to prevent overexposure. Option A is incorrect as isolation under airborne precautions is not required for brachytherapy. Option B and C are the correct choices as they focus on minimizing radiation exposure to others, ensuring safety during treatment.

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