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 requires maximal support is being taught how to use a two-wheeled walker by a nurse. Which of the following actions by the client indicates an understanding of the teaching?

• A. The client moves the walker ahead 25.4 cm with each step
• B. The client picks up the walker with each step
• C. The client stands with elbows slightly bent while holding the walker
• D. The client stoops slightly forward when moving the walker

Correct answer: C

Rationale: The correct answer is C. When using a two-wheeled walker, the client should stand with elbows slightly bent to maintain balance and stability. This position helps distribute weight effectively and promotes proper use of the walker. Choices A, B, and D are incorrect. Choice A does not demonstrate proper posture while using the walker. Choice B of picking up the walker with each step is not the correct technique and can lead to instability. Choice D of stooping slightly forward is also incorrect as it can affect balance and posture negatively.

3. A healthcare provider is assessing a client with a diagnosis of acute pancreatitis. Which laboratory value would be most concerning?

• A. Serum amylase of 200 U/L
• B. Serum lipase of 250 U/L
• C. Blood glucose of 200 mg/dL
• D. Serum calcium of 7.5 mg/dL

Correct answer: D

Rationale: In acute pancreatitis, hypocalcemia (low serum calcium) is a critical finding that is associated with a poor prognosis and requires immediate attention. Serum amylase and lipase are typically elevated in acute pancreatitis due to pancreatic inflammation, but they are not indicators of severity. Blood glucose levels may be elevated due to stress or underlying conditions but are not directly related to the severity of acute pancreatitis. Therefore, the most concerning value in this scenario is the low serum calcium level, which can have significant implications for the client's prognosis.

4. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first?

• A. Establish a toileting schedule to decrease episodes of incontinence
• B. Complete a functional assessment of the client's self-care abilities
• C. Apply a barrier ointment to intact areas that may be exposed to moisture
• D. Determine the size and depth of skin breakdown over the sacral area

Correct answer: D

Rationale: The first action the nurse should implement is to determine the size and depth of the skin breakdown over the sacral area. This initial assessment will provide crucial information on the extent of the damage and guide appropriate care interventions. Option A is not the priority in this scenario as the immediate concern is addressing the existing skin breakdown. Option B, completing a functional assessment, is important but should come after addressing the acute issue of skin breakdown. Option C, applying a barrier ointment, may be beneficial later but does not address the primary need of assessing the extent of the current skin damage.

5. Twenty minutes after starting a heat application, the client mentions that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN?

• A. That indicates you have derived the maximum benefit, and the heat can be removed.
• B. Your blood vessels are dilating and removing the heat from the site.
• C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
• D. The body's receptors adapt over time as they are exposed to heat.

Correct answer: D

Rationale: Choice D is the correct response. The body's receptors adapt to the heat over time, which can explain why the client no longer perceives the warmth from the heating pad. This phenomenon is known as thermal adaptation. Choices A, B, and C are incorrect. Choice A is inaccurate because the client not feeling the warmth does not necessarily mean they have derived the maximum benefit. Choice B incorrectly states that blood vessels dilating remove heat, which is not accurate. Choice C suggests increasing the temperature when the pad no longer feels warm, which could potentially lead to burns or discomfort for the client.

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