Nursing Elites

1. A client with difficulty self-feeding due to rheumatoid arthritis should be referred to which member of the interprofessional care team to use adaptive devices?

• A. Social worker
• B. Certified nursing assistant
• C. Registered dietitian
• D. Occupational therapist

Correct answer: D

Rationale: The correct answer is D, Occupational therapist. Occupational therapists specialize in assisting clients with adaptive devices to enhance their ability to perform daily activities like self-feeding. They evaluate client needs and provide interventions to promote independence in activities of daily living. Choice A, Social worker, focuses on psychosocial support and community resources, not directly addressing the physical aspect of self-feeding difficulty. Choice B, Certified nursing assistant, is involved in direct patient care but lacks specialized training in adaptive devices. Choice C, Registered dietitian, primarily focuses on nutrition-related issues and may not have the expertise in adaptive devices and functional rehabilitation necessary for this client's self-feeding challenges.

2. A client with congestive heart failure (CHF) is receiving furosemide (Lasix). Which laboratory value should the LPN monitor closely while the client is taking this medication?

• A. Sodium
• B. Potassium
• C. Calcium
• D. Magnesium

Correct answer: B

Rationale: The LPN should monitor potassium levels closely while the client is taking furosemide (Lasix) due to the medication's potential to cause hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through increased urine output. Hypokalemia can result in serious complications such as cardiac dysrhythmias. Monitoring sodium levels (choice A) is important but not as critical as monitoring potassium in this context. Calcium (choice C) and magnesium (choice D) levels are not typically affected by furosemide and are not the priority for monitoring in this scenario.

3. A client with diabetes mellitus reports feeling anxious, shaky, and weak. These findings are manifestations of which of the following complications?

• A. Hyperglycemia
• B. Hypoglycemia
• C. Ketoacidosis
• D. Dawn phenomenon

Correct answer: B

Rationale: The correct answer is B, Hypoglycemia. In diabetes mellitus, hypoglycemia can lead to symptoms such as anxiety, shakiness, and weakness due to low blood sugar levels. Hyperglycemia (choice A) is high blood sugar levels and typically presents with symptoms like increased thirst and frequent urination. Ketoacidosis (choice C) is a serious complication of diabetes characterized by high levels of ketones in the blood, leading to symptoms such as fruity breath and rapid breathing. The Dawn phenomenon (choice D) refers to an abnormal early-morning increase in blood sugar levels without an associated hypoglycemia during the night.

4. A client has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?

• A. Wear gloves when changing the client's gown.
• B. Use hand sanitizer after contact with the client.
• C. Wear a mask when entering the client's room.
• D. Clean the room with a disinfectant spray.

Correct answer: A

Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile in contact isolation is to wear gloves when changing the client's gown. Clostridium difficile is highly transmissible, and wearing gloves helps prevent the spread of the infection. Using hand sanitizer after contact with the client (Choice B) is not enough to prevent the transmission of C. difficile, as the spores can persist and spread. Wearing a mask when entering the client's room (Choice C) is not necessary for C. difficile transmission, which primarily occurs through contact with contaminated surfaces. Cleaning the room with a disinfectant spray (Choice D) is important, but wearing gloves during direct care is the priority to prevent the nurse from acquiring and spreading the infection.

5. A nurse is planning care for a client who has a prescription for knee-length anti-embolic stockings. Which of the following actions should the nurse take?

• A. Remove the client’s stockings at least once during each shift
• B. Roll the top of the client’s stockings down to just below the knee
• C. Seat the client in a chair for 30 minutes prior to applying stockings
• D. Measure the length of the client’s leg from the heel to the gluteal fold

Correct answer: A

Rationale: The correct action for the nurse to take is to remove the client’s stockings at least once during each shift. This is important to inspect the skin and prevent complications such as pressure injuries or impaired circulation. Rolling the top of the stockings down can compromise their effectiveness in preventing blood clots. Seating the client in a chair prior to applying stockings is not directly related to the care of anti-embolic stockings. Measuring the length of the client’s leg from the heel to the gluteal fold is not necessary for the application or care of knee-length anti-embolic stockings.

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