Nursing Elites

1. While turning and positioning a bedfast client, the PN observes that the client is dyspneic. Which action should the PN take first?

• A. Apply a pulse oximeter
• B. Measure blood pressure
• C. Notify the charge nurse
• D. Observe pressure areas

Correct answer: C

Rationale: Notifying the charge nurse promptly is the priority when a bedfast client is dyspneic. Dyspnea can indicate a serious problem that requires immediate assessment and intervention. Contacting the charge nurse ensures timely assistance and appropriate actions to address the client's condition. Applying a pulse oximeter or measuring blood pressure may provide valuable data, but the priority is prompt communication with the charge nurse to ensure quick intervention. Observing pressure areas, while important for overall client care, is not the most immediate action needed when a client is experiencing dyspnea.

2. After a laparoscopic cholecystectomy, what is the most important instruction the nurse should give the client regarding post-operative care at home?

• A. Avoid lifting heavy objects for at least a week.
• B. Follow a low-fat diet.
• C. Monitor the incision sites for signs of infection.
• D. Resume normal activities as tolerated.

Correct answer: C

Rationale: Monitoring the incision sites for signs of infection is crucial after a laparoscopic cholecystectomy. Infections can lead to serious complications if not detected early. While avoiding heavy lifting and following a low-fat diet are important aspects of recovery, monitoring for infection takes precedence as it directly impacts the client's immediate post-operative well-being. Therefore, option C is the correct answer as it addresses the most critical aspect of post-operative care.

3. What is the function of the epiglottis during swallowing?

• A. Prevents food from entering the trachea
• B. Aids in food propulsion
• C. Enhances taste sensation
• D. Lubricates the esophagus

Correct answer: A

Rationale: The epiglottis is a flap of tissue that closes over the trachea during swallowing to prevent food and liquids from entering the airway. Choice A is correct because the primary function of the epiglottis is to act as a lid over the trachea, ensuring that food goes down the esophagus and not into the windpipe. Choices B, C, and D are incorrect as they do not describe the specific role of the epiglottis during swallowing.

4. The PN is caring for a client who had an acute brain attack with resulting expressive aphasia and urinary incontinence. To ensure care for the client, which task should the PN delegate to the UAP?

• A. Explain how to use a communication board
• B. Document progress in the use of the communication board
• C. Encourage voiding by assisting the client to the bedside commode
• D. Establish a bladder training schedule and methods

Correct answer: C

Rationale: Assisting the client to the bedside commode is an appropriate task for the UAP as it involves basic patient care and mobility assistance, which are within the UAP's scope of practice. Options A and B involve communication techniques and documentation, which are more appropriate for licensed nursing staff. Option D involves establishing a bladder training schedule, which requires assessment and planning skills beyond the UAP's role.

5. A nurse is assessing a day-old infant for jaundice. Which of the following is the best method for this?

• A. Applying pressure over a bony area such as the forehead and evaluating the skin color after the pressure is removed
• B. Assessing the color of the infant’s hands and feet
• C. Assessing the infant’s tongue
• D. Assessing the infant’s arms and legs

Correct answer: A

Rationale: The correct answer is A. Applying pressure over a bony area and evaluating the skin color after the pressure is removed is the most accurate method for assessing jaundice in a day-old infant. This technique helps in identifying any yellowing of the skin, which is a key indicator of jaundice. Choices B, C, and D are less effective methods for assessing jaundice in a newborn. Assessing the color of the hands and feet may not give a reliable indication of jaundice, while evaluating the tongue, arms, and legs are not as specific or accurate as applying pressure over a bony area.

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