Nursing Elites

1. A client enters the emergency department unconscious via ambulance from the client's workplace. What document should be given priority to guide the direction of care for this client?

• A. The statement of client rights and the client self-determination act
• B. Orders written by the healthcare provider
• C. A notarized original of advance directives brought in by the partner
• D. The clinical pathway protocol of the agency and the emergency department

Correct answer: C

Rationale: In this scenario, when the client is unconscious and unable to make decisions, a notarized original of advance directives brought in by the partner should be given priority to guide the direction of care. Advance directives provide legal documentation of the client's wishes regarding healthcare decisions in situations where they cannot express their preferences. The statement of client rights and the client self-determination act (Choice A) outlines general principles but does not provide specific guidance on the client's care. Orders written by the healthcare provider (Choice B) are important but may not reflect the client's preferences. Clinical pathway protocols (Choice D) are useful for standard care pathways but do not address individual client wishes.

2. A client is being taught how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands?

• A. I will straighten my ear canal by pulling my ear down and back.
• B. I will gently apply pressure with my finger to the front part of my ear after putting in the drops.
• C. I will insert the nozzle of the ear drop bottle snugly into my ear before squeezing the drops in.
• D. After the drops are in, I will place a cotton ball all the way into my ear canal.

Correct answer: B

Rationale: The correct answer is B. Gently applying pressure to the front part of the ear after administering drops helps with absorption. Pulling the ear down and back is a correct technique for adults. Snugly inserting the nozzle of the ear drop bottle or placing a cotton ball all the way into the ear canal is unnecessary and can potentially cause harm or discomfort. Therefore, choices A, C, and D are incorrect.

3. A client with amphetamine toxicity and sensory overload is being cared for by a nurse. Which intervention should the nurse implement?

• A. Immediately conduct a thorough assessment.
• B. Encourage visitors to distract the client.
• C. Provide a private room and limit stimulation.
• D. Speak softly to the client.

Correct answer: C

Rationale: The most appropriate intervention for a client with amphetamine toxicity and sensory overload is to provide a private room and limit stimulation. This approach helps reduce external stimuli, which can exacerbate sensory overload, and creates a calming environment for the client. Encouraging visitors to distract the client may worsen sensory overload by adding more stimulation. Speaking softly, rather than at a higher volume, is more suitable to help maintain a calm environment. Therefore, the correct choice is to provide a private room and limit stimulation (option C) in this scenario.

4. The nurse is caring for a client with diabetes insipidus. Which finding should the LPN/LVN report to the healthcare provider?

• A. Weight gain
• B. Increased urine output
• C. Low blood pressure
• D. Thirst

Correct answer: B

Rationale: The correct answer is B: Increased urine output. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large amounts of dilute urine. Reporting increased urine output is crucial as it is a hallmark sign of diabetes insipidus. Weight gain (choice A) is not typically associated with diabetes insipidus; instead, clients may experience weight loss due to fluid loss. Low blood pressure (choice C) can be a complication of diabetes insipidus due to dehydration from excessive urination, but the priority finding to report is the increased urine output. Thirst (choice D) is a common symptom of diabetes insipidus due to the body's attempt to compensate for fluid loss, but it is not the most critical finding to report.

5. A healthcare professional is planning to document care provided for a client. Which of the following abbreviations should the professional use?

• A. PC for after meals
• B. QD for every day
• C. BID for twice a day
• D. PRN for as needed

Correct answer: A

Rationale: The correct answer is A: PC for after meals. PC stands for 'post cibum,' which is the appropriate abbreviation for 'after meals' in medical documentation. Choices B, QD, and C, BID, represent 'every day' and 'twice a day,' respectively, which are not specific to meal times. Choice D, PRN, signifies 'as needed,' which is also not related to meal timings. Therefore, for documenting care provided after meals, the most suitable abbreviation is PC.

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