Nursing Elites

1. The PN determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the PN take?

• A. Protect the client's feet from injury
• B. Apply a heating pad to the affected area
• C. Keep the client's feet elevated
• D. Assess the feet and legs for jaundice

Correct answer: A

Rationale: Protecting the client's feet from injury is the most appropriate action for a client with cirrhosis experiencing peripheral neuropathy. Peripheral neuropathy can lead to a loss of sensation, making the client prone to unnoticed injuries. Applying a heating pad (Choice B) is contraindicated as it may cause burns or further damage to the affected area. Keeping the client's feet elevated (Choice C) is not directly related to managing peripheral neuropathy and may not provide significant benefit. Assessing the feet and legs for jaundice (Choice D) is important for monitoring liver function in clients with cirrhosis, but in this case, the priority is to prevent injury to the feet due to decreased sensation.

2. Rehabilitation after illness is classified under which level of healthcare?

• A. Primary
• B. Secondary
• C. Tertiary
• D. All three

Correct answer: C

Rationale: Rehabilitation after illness is classified as tertiary care. Tertiary care aims to help patients recover from illness, injuries, or disabilities, and restore their functionality. Primary care involves preventive measures and early disease detection, while secondary care focuses on diagnosis and treatment of specific conditions. Therefore, choices A, B, and D are incorrect as they do not specifically address the specialized nature of rehabilitation in healthcare.

3. The PN observes a UAP preparing to exit a client's room. The UAP's hands appear visibly soiled as the UAP uses a hand rub for 19 seconds to cleanse the hands. Which action should the PN take?

• A. Confirm that the UAP completed hand hygiene correctly
• B. Instruct the UAP to wash the hands for one minute
• C. Ask the UAP why the hands were so obviously soiled
• D. Advise the UAP to use the hand rub for 30 seconds

Correct answer: D

Rationale: When hands are visibly soiled, they should be washed with soap and water for at least 20 seconds. However, when using hand rub, it should be applied for at least 30 seconds to be effective. In this scenario, the UAP's hands were visibly soiled, indicating the need for thorough cleaning. Advising the UAP to use the hand rub for 30 seconds is essential to ensure proper hand hygiene and reduce the risk of spreading infection. Choices A, B, and C are incorrect because confirming completion of hand hygiene, instructing to wash for one minute, or asking why the hands were soiled do not address the immediate need for proper hand hygiene in the given situation.

4. What is the primary function of hemoglobin in red blood cells?

• A. To transport oxygen from the lungs to body tissues
• B. To protect the body from infections
• C. To help in blood clotting
• D. To regulate body temperature

Correct answer: A

Rationale: The primary function of hemoglobin in red blood cells is to transport oxygen from the lungs to body tissues and return carbon dioxide from the tissues to the lungs. Hemoglobin binds to oxygen in the lungs and releases it in the body's tissues. Choice B is incorrect because hemoglobin is not involved in protecting the body from infections. Choice C is incorrect because blood clotting is mainly facilitated by platelets and clotting factors, not hemoglobin. Choice D is incorrect because the regulation of body temperature is mainly controlled by processes like sweating and shivering, not by hemoglobin.

5. The nurse is providing care for a client with type 1 diabetes mellitus who is receiving NPH insulin. The nurse notices that the client's evening glucose levels are consistently above 260 mg/dl. What does this indicate?

• A. States that her feet are constantly cold and feel numb
• B. A wound on the ankle that starts to drain and becomes painful
• C. Consecutive evening serum glucose greater than 260 mg/dl
• D. Reports nausea in the morning but still able to eat breakfast

Correct answer: C

Rationale: High evening glucose levels suggest that the current insulin dosage may be inadequate to control the client's blood sugar levels effectively. This indicates poor glycemic control and the need for a possible adjustment in the insulin regimen. Option A describes symptoms of peripheral neuropathy, which are not directly related to the elevated glucose levels but may be a long-term complication of diabetes. Option B describes a wound infection, which is not directly related to the client's high glucose levels. Option D mentions morning nausea, which could be due to various causes and is not directly related to the high evening glucose levels.

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