Nursing Elites

1. A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

• A. Evacuate the client
• B. Attempt to extinguish the fire
• C. Call the fire department
• D. Close the door to contain the fire

Correct answer: A

Rationale: The correct answer is to Evacuate the client (Choice A). In the event of a fire, the safety of the client is the top priority. The RACE (Rescue, Alarm, Contain, Extinguish) mnemonic is used in fire emergencies. The first step is to Rescue or Evacuate the individual from immediate danger. Attempting to extinguish the fire (Choice B) may endanger both the client and the nurse. Calling the fire department (Choice C) is important but should come after ensuring the client's safety. Closing the door to contain the fire (Choice D) is not appropriate in this scenario because the priority is to remove the client from harm's way.

2. A client with a history of congestive heart failure (CHF) is admitted with dyspnea and a productive cough. What is the most important assessment for the LPN/LVN to perform?

• A. Measure the client's urine output.
• B. Auscultate the client's lung sounds.
• C. Assess the client's apical pulse.
• D. Check the client's blood pressure.

Correct answer: B

Rationale: Auscultating lung sounds is crucial for assessing the extent of congestion in a client with CHF. The presence of crackles or wheezing can indicate fluid accumulation in the lungs, a common complication of CHF. Monitoring urine output (Choice A) is important to assess renal function but is not the priority in this situation. While assessing the apical pulse (Choice C) and checking blood pressure (Choice D) are important in managing CHF, they do not provide immediate information about the respiratory status and congestion level in the lungs, making auscultating lung sounds the most critical assessment.

3. The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area?

• A. Neck, shoulders, and chest
• B. Abdomen and groin/perineum
• C. Legs, feet, and web spaces
• D. Back of neck, back, and then buttocks

Correct answer: B

Rationale: In providing a complete bed bath using a bag bath for an unconscious patient, the nurse should follow a specific order. The correct sequence is as follows: Neck, shoulders, and chest; Both arms, both hands, web spaces, and axilla; Abdomen and then groin/perineum; Right leg, right foot, and web spaces; Left leg, left foot, and web spaces; Back of neck, back, and then buttocks. Choice A is incorrect as it does not follow the correct sequence for a bed bath. Choice C is incorrect as it focuses on the lower extremities before addressing the upper body. Choice D is incorrect as it starts with the back of the patient instead of the upper body areas first.

4. A healthcare professional is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the professional obtain to assess for this condition?

• A. Thermometer
• B. Elastic stockings
• C. Blood pressure cuff
• D. Sequential compression devices

Correct answer: C

Rationale: To assess for orthostatic hypotension, a healthcare professional needs to obtain a blood pressure cuff. Orthostatic hypotension is defined as a drop in blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure when moving from lying down to a standing position. A thermometer (Choice A) is used to measure body temperature and is not directly related to assessing orthostatic hypotension. Elastic stockings (Choice B) are used for preventing deep vein thrombosis and improving circulation in the lower extremities, not for assessing orthostatic hypotension. Sequential compression devices (Choice D) are mechanical pumps that are used to prevent deep vein thrombosis and are not specifically used for assessing orthostatic hypotension.

5. 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.

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