Nursing Elites

1. During surgery, it is found that a client with adenocarcinoma of the rectum has positive peritoneal lymph nodes. What is the next most likely site of metastasis?

• A. brain
• B. bone
• C. liver
• D. mediastinum

Correct answer: C

Rationale: In cases of adenocarcinoma of the rectum with positive peritoneal lymph nodes, the most likely site of metastasis is the liver. Colon tumors commonly spread through the lymphatics and portal vein to the liver. While metastasis to the brain, bone, or mediastinum is possible, the liver is typically the first to be affected due to the anatomical pathways involved in colorectal cancer metastasis. Therefore, the correct answer is the liver. Metastasis to the brain, bone, or mediastinum would be less likely at this stage of colorectal cancer progression.

2. An LPN is working on the care plan for a client with diabetes mellitus. Which of these outcomes would be the most appropriate?

• A. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
• B. The client will maintain a blood glucose level within normal range limits today.
• C. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
• D. The client will maintain a blood glucose level within normal limits throughout my shift.

Correct answer: C

Rationale: The correct answer is 'The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.' This outcome is specific, measurable, and aligns with the goal of managing diabetes mellitus. Choice A is correct because it provides a clear target range (70-110) and includes adherence to facility policy, making it precise and goal-oriented. Choice B lacks specificity on the timeframe, and Choice D is vague in defining the target blood glucose range. In nursing care plans, outcomes should be well-defined, achievable, and measurable to effectively monitor the client's progress in managing their condition.

3. All of the following tasks could be delegated to a nursing assistant or unlicensed assistive personnel (UAP) except:

• A. monitoring intravenous infusion
• B. assisting a client to the bathroom
• C. offering fluid intake every 1-2 hours
• D. monitoring/recording the amount of fluid taken

Correct answer: A

Rationale: Monitoring an intravenous infusion involves assessing for complications, adjusting the flow rate, and monitoring the client's response, which requires the knowledge and skills of a licensed nurse (RN or LPN). Tasks that can be delegated to nursing assistants or unlicensed assistive personnel include assisting a client to the bathroom, offering fluids, and recording fluid intake. These activities are within the scope of practice for UAPs as they do not involve the specialized knowledge and training needed for intravenous infusion monitoring.

4. A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife?

• A. A bone scan is being performed.
• B. She can read the client's medical record to determine what the health care provider prescribed.
• C. The radiology department is not clear as to which test has been prescribed.
• D. She will have to discuss the prescribed test with the client.

Correct answer: D

Rationale: In healthcare, confidentiality is crucial. Without the client's consent, nurses cannot disclose confidential information to anyone else, even to family members. Therefore, the appropriate response is to inform the client's wife that she will have to discuss the test with the client directly. It is not appropriate to disclose sensitive medical information without the client's permission. Offering the wife to read the medical record is a violation of privacy and confidentiality. Indicating that the radiology department is unclear about the prescribed test is inaccurate and does not uphold confidentiality. Moreover, it is not the responsibility of another department to disclose medical information; it is the duty of the healthcare provider and the client to discuss such matters.

5. The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate a need for teaching reinforcement?

• A. "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."?
• B. "I should remain sitting up at a 45-degree angle or higher for 30 minutes after a feeding."?
• C. "I can clean around the tube with water and mild soap."?
• D. "I should avoid using Vaseline around the nostril and tube."?

Correct answer: A

Rationale: The correct answer is, "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."? This statement indicates a need for teaching reinforcement because even when an NG tube is in place, the client should still brush their teeth twice daily. Good oral hygiene is essential to reduce the risk of introducing bacteria that may cause an infection. Choice B is incorrect because remaining sitting up at a 45-degree angle or higher for 30 minutes after a feeding is a correct statement regarding NG tube care, promoting proper digestion and reducing the risk of aspiration. Choice C is also incorrect because cleaning around the tube with water and mild soap is an appropriate practice to maintain cleanliness and prevent infection. Choice D is incorrect because advising to avoid using Vaseline around the nostril and tube is a proper instruction to prevent skin breakdown, occlusion of the tube, and potential aspiration of Vaseline into the lungs.

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