Nursing Elites

1. A client with a history of peptic ulcer disease reports black, tarry stools. What is the most appropriate action for the LPN/LVN to take?

• A. Reassure the client that this is not a normal finding.
• B. Notify the healthcare provider immediately.
• C. Document the finding in the client’s chart.
• D. Encourage the client to seek medical attention.

Correct answer: B

Rationale: The correct answer is B: Notify the healthcare provider immediately. Black, tarry stools can be indicative of gastrointestinal bleeding, a serious complication that requires urgent medical evaluation and intervention. This finding should not be dismissed or considered normal without further assessment. Option A is incorrect because black, tarry stools are not a normal finding and may signify a significant health issue. Option C is incorrect as immediate action is needed rather than just documenting the finding. Option D is not the best choice as it simply suggests seeking medical attention without emphasizing the urgency of the situation. Prompt notification of the healthcare provider is crucial to ensure timely intervention and management of potential gastrointestinal bleeding.

2. A client requires bed rest and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take?

• A. Apply the stockings with the creases on the front of the leg.
• B. Apply the stockings while the client's legs are in a dependent position.
• C. Remove the stockings at least once per shift.
• D. Remove the stockings while the client is sitting in a reclining chair.

Correct answer: C

Rationale: The correct action for the nurse to take is to remove the anti-embolic stockings at least once per shift. This is essential to assess the client's circulation and skin integrity. Option A is incorrect because the stockings should be applied without creases to ensure proper compression. Option B is incorrect as the stockings should be applied when the client's legs are elevated, not in a dependent position. Option D is incorrect as removing the stockings while the client is sitting in a reclining chair is not necessary and does not provide the appropriate assessment opportunity.

3. A client with a history of hypertension is prescribed a diuretic. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the medication?

• A. Monitor serum calcium levels.
• B. Monitor serum potassium levels.
• C. Monitor serum sodium levels.
• D. Monitor serum magnesium levels.

Correct answer: B

Rationale: The correct answer is to monitor serum potassium levels. When a client is prescribed a diuretic, monitoring serum potassium levels is essential to evaluate the medication's effectiveness and to detect potential electrolyte imbalances. Diuretics can cause potassium loss, leading to hypokalemia, which can have serious consequences such as cardiac arrhythmias. Monitoring serum calcium levels (Choice A) is not typically required when assessing the effectiveness of diuretics. Similarly, monitoring serum sodium levels (Choice C) is important for other conditions but is not the primary concern when evaluating diuretic therapy. Monitoring serum magnesium levels (Choice D) is also important, but potassium levels are more critical in assessing diuretic effectiveness and preventing complications.

4. A healthcare professional is planning to perform ear irrigation on an adult client with impacted cerumen. Which of the following should the professional plan to take?

• A. Wearing sterile gloves while performing irrigation
• B. Positioning the client with the affected side down following irrigation
• C. Using cool fluid to irrigate the ear canal
• D. Pulling the pinna downward during irrigation

Correct answer: B

Rationale: Positioning the client with the affected side down following irrigation is crucial as it helps facilitate drainage of the dislodged cerumen and any remaining irrigation solution. This position allows gravity to assist in the removal of the loosened debris. Wearing sterile gloves is a standard precaution in healthcare procedures to prevent infection but is not specific to ear irrigation. Using body-temperature water or a solution at a slightly warmer temperature is recommended to prevent vertigo and discomfort, so using cool fluid is incorrect. Pulling the pinna upward and backward, not downward, straightens the ear canal for adults to facilitate the irrigation process, making choice D incorrect.

5. Before donning gloves to perform a procedure, proper hand hygiene is essential. The healthcare professional understands that the most important aspect of hand hygiene is the amount of:

• A. Temperature
• B. Time
• C. Friction
• D. Soap

Correct answer: C

Rationale: The correct answer is C: Friction. The amount of friction is crucial in effective hand hygiene to remove microorganisms. Rubbing hands together with friction helps to dislodge and remove dirt, oils, and microorganisms. While temperature and soap are important factors in hand hygiene, the mechanical action of friction plays a more significant role in physically removing contaminants. Time is also important in hand hygiene practice, but without adequate friction, the effectiveness of the process is compromised.

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