Nursing Elites

1. A client who is 5'5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the LPN to include during the preoperative assessment?

• A. What is your daily calorie consumption?
• B. What vitamin and mineral supplements do you take?
• C. Do you feel that you are overweight?
• D. Will a clear liquid diet be okay after surgery?

Correct answer: B

Rationale: During the preoperative assessment, it is crucial for the LPN to inquire about the client's intake of vitamin and mineral supplements. This is important because certain supplements can have effects on coagulation, wound healing, and overall surgical outcomes. Asking about daily calorie consumption (Choice A) is not as pertinent as inquiring about vitamin and mineral supplements in this context. Questioning the client about feeling overweight (Choice C) may not directly impact the surgical outcome compared to the effects of supplements. Inquiring about the post-surgery diet (Choice D) is relevant but not as critical as understanding the client's supplement intake.

2. A client is experiencing dyspnea and fatigue after completing morning care. Which of the following actions should the nurse include in the client’s plan of care?

• A. Schedule rest periods during morning care.
• B. Discontinue morning care for 2 days.
• C. Perform all care as quickly as possible.
• D. Ask a family member to come in to bathe the client.

Correct answer: A

Rationale: Scheduling rest periods during morning care is essential for managing dyspnea and fatigue in the client. This approach allows the client to pace themselves and catch their breath, promoting comfort and reducing symptoms. It is crucial to provide breaks to prevent overwhelming the client and exacerbating their symptoms. Discontinuing morning care for 2 days (choice B) is not a suitable solution as it does not address the underlying issue and may lead to neglect of essential care. Performing all care as quickly as possible (choice C) can worsen the client's symptoms and compromise their well-being by increasing stress and exertion. Asking a family member to bathe the client (choice D) does not address the need for rest periods during care and may not be feasible or appropriate in all situations.

3. A client with a tracheostomy is being taught by a nurse and their family how to care for the tracheostomy at home. Which of the following should the nurse include in the teaching?

• A. Use tracheostomy covers when outdoors.
• B. Clean the tracheostomy with alcohol.
• C. Replace the tracheostomy tube every week.
• D. Cover the tracheostomy with a wet cloth when sleeping.

Correct answer: A

Rationale: Using tracheostomy covers when outdoors is essential to protect the tracheostomy from dust and debris, reducing the risk of infection. Tracheostomy covers help maintain cleanliness and prevent foreign particles from entering the stoma. Choice B is incorrect because cleaning the tracheostomy with alcohol can be too harsh and drying for the skin surrounding the stoma, leading to skin irritation. Choice C is incorrect as tracheostomy tubes are typically replaced only when clinically indicated or as per the healthcare provider's instructions, not routinely every week, to prevent unnecessary risks and complications. Choice D is incorrect as covering the tracheostomy with a wet cloth when sleeping can create a moist environment ideal for bacterial growth, increasing the risk of infection and skin breakdown. It is important to keep the tracheostomy site clean, dry, and protected to maintain optimal hygiene and prevent complications.

4. A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?

• A. Assessment
• B. Plan of care
• C. Client history
• D. Medication list

Correct answer: A

Rationale: The correct answer is A: Assessment. When admitting a client, the nurse should document assessment data first. This information is crucial as it provides a baseline for planning care and treatment. By documenting the assessment initially, the nurse can accurately identify the client's needs and prioritize care. Choice B, Plan of care, would be developed based on the assessment findings, so it should come after the initial assessment. Choices C and D, Client history and Medication list, are important but would typically be documented after the assessment to ensure that the most current and relevant information is captured in the client's record.

5. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse?

• A. Reassure the client that he will become accustomed to the stoma's appearance in time.
• B. Instruct the client that the stoma will become smaller when the initial swelling diminishes.
• C. Offer to contact a member of the local ostomy support group to help him with his concerns.
• D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

Correct answer: B

Rationale: The correct response is to instruct the client that the stoma will become smaller when the initial swelling diminishes. This explanation helps reassure the client about the temporary appearance of the stoma. Choice A is incorrect because simply reassuring the client that he will become accustomed to the stoma's appearance does not address the immediate concern about the stoma size. Choice C is incorrect because offering to contact a support group does not directly address the client's current distress about the stoma size. Choice D is incorrect because encouraging the client to handle stoma equipment does not directly address the client's concern about the stoma size and may not be appropriate at this time.

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