Nursing Elites

1. A nurse is observing a newly licensed nurse providing care for a client who reports pain. The nurse checked the client’s MAR and noted the last dose of pain medication was administered 6 hours ago. The prescription specifies administration every 4 hours PRN for pain. The nurse administered the medication and followed up with the client 40 minutes later, who reported improvement. What did the newly licensed nurse overlook in the nursing process?

• A. Assessment
• B. Planning
• C. Intervention
• D. Evaluation

Correct answer: A

Rationale: The correct answer is 'Assessment.' In the nursing process, assessment is the first step, crucial before any intervention. Assessment involves gathering data about the client's condition to establish a baseline for evaluating responses to interventions. In this scenario, the newly licensed nurse missed assessing the client's pain intensity, location, quality, and other relevant factors before administering the pain medication. While the follow-up evaluation with the client is commendable, it cannot replace the initial assessment. Planning involves setting goals and outcomes, intervention is the action taken to achieve these goals, and evaluation assesses the client's response to the intervention.

2. A client who has a new prescription for warfarin (Coumadin) is receiving discharge instructions. Which statement indicates the client understands the teaching?

• A. I will take my warfarin at the same time every day.
• B. I should increase my intake of green leafy vegetables.
• C. I should use a soft-bristled toothbrush while taking this medication.
• D. I should avoid drinking alcohol while taking this medication.

Correct answer: C

Rationale: The correct answer is C: 'I should use a soft-bristled toothbrush while taking this medication.' Using a soft-bristled toothbrush is crucial as it helps prevent bleeding gums, which is a potential side effect of warfarin therapy. Option A about taking warfarin at the same time every day is a good practice but does not directly relate to preventing side effects. Option B suggesting an increase in green leafy vegetables can interfere with warfarin's anticoagulant effects due to their vitamin K content. Option D advising to avoid alcohol is generally recommended but is not directly related to the specific side effects of warfarin.

3. A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the LPN give the client about this medication?

• A. Prolonged use does not typically cause dark concentrated urine.
• B. It is not necessary to take the medication on an empty stomach for optimal absorption.
• C. Avoid taking the medication with aluminum hydroxide to minimize GI upset.
• D. Drinking alcohol daily can cause drug-induced hepatitis.

Correct answer: D

Rationale: The correct answer is D. When taking isoniazid, alcohol consumption should be avoided as it can increase the risk of liver damage, potentially leading to drug-induced hepatitis. Choices A, B, and C are incorrect. Prolonged use of isoniazid does not typically cause dark concentrated urine; it is not necessary to take the medication on an empty stomach for optimal absorption; and it is not recommended to take isoniazid with aluminum hydroxide to minimize GI upset.

4. A client with a new colostomy is being taught how to irrigate the ostomy. The healthcare provider realizes that the client needs further teaching when the client:

• A. Positions the irrigating solution bag 30 inches below the stoma
• B. Uses an open system for irrigation
• C. Irrigates the colostomy twice a day
• D. Cleans the stoma with harsh chemicals

Correct answer: A

Rationale: The correct answer is A. Positioning the irrigating solution bag 30 inches below the stoma would cause discomfort and ineffective irrigation as the bag should be positioned at a lower level. Option B is incorrect because a closed system for irrigation is the preferred method for colostomy irrigation. Option C is incorrect as colostomy irrigation is typically done once a day unless otherwise instructed by a healthcare provider. Option D is incorrect as the stoma should be cleaned with mild soap and water to prevent skin irritation and damage.

5. The healthcare provider is planning care for a 3-month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The healthcare provider needs to

• A. Assess for abdominal distention
• B. Maintain the infant in an upright position
• C. Begin feeding formula when the infant is alert
• D. Pump the shunt to assess for proper function

Correct answer: A

Rationale: Assessing for abdominal distention is crucial in this situation as it can indicate a complication with the shunt or fluid accumulation. Abdominal distention may suggest an issue with the shunt placement, such as obstruction or overdrainage, which requires immediate intervention. Maintaining the infant in an upright position (Choice B) is not the priority immediately postoperatively following a ventriculoperitoneal shunt placement. Beginning formula feedings when the infant is alert (Choice C) may be appropriate but is not the priority over assessing for abdominal distention. Pumping the shunt to assess for proper function (Choice D) is not a recommended nursing intervention postoperatively and should be done by a qualified healthcare provider.

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