Nursing Elites

1. A nurse in a surgical suite notes documentation on a client's medical record stating that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

• A. Ensure sterilization of non-disposable items with ethylene oxide
• B. Wrap monitoring cords with stockinette and secure them with non-latex tape
• C. Cleanse latex ports on IV tubing with chlorhexidine before administering medication
• D. Wear hypoallergenic latex gloves that are powder-free

Correct answer: B

Rationale: In this scenario, the nurse should take precautions to prevent latex exposure to the client due to his latex allergy. Wrapping monitoring cords with stockinette and securing them with non-latex tape helps to minimize the risk of latex contact with the client. Choice A is incorrect as sterilizing non-disposable items with ethylene oxide does not specifically address the avoidance of latex exposure. Choice C involves using latex ports on IV tubing, which can pose a risk of allergic reaction in a client with a latex allergy. Choice D suggests wearing latex gloves, even if hypoallergenic, which can still trigger a reaction in individuals with latex allergy. Therefore, the best option is to choose non-latex materials like stockinette and non-latex tape to prevent direct contact with latex.

2. A patient's neighbor is scheduled for elective surgery. The neighbor’s provider indicated that a moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. Which of the following is appropriate for the nurse to suggest?

• A. Avoid the blood transfusion
• B. Donate autologous blood before the surgery
• C. Use a blood substitute
• D. Take antibiotics before the surgery

Correct answer: B

Rationale: Donating autologous blood before surgery is an appropriate suggestion by the nurse. This process involves the patient donating their own blood before the surgery, which reduces the risk of infection from transfusions as the patient is receiving their own blood. Choice A is incorrect as avoiding the blood transfusion may not be feasible or safe in the context of expected blood loss during surgery. Choice C is not a common practice and may carry its own risks. Choice D is not directly related to reducing the risk of infection from a blood transfusion.

3. The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take?

• A. Directly address the child instead of the mother.
• B. Continue asking the mother questions about the child.
• C. Request another nurse to interview the mother now.
• D. Politely ask the mother to look at you when answering.

Correct answer: B

Rationale: In this scenario, the LPN should continue asking the mother questions about the child. The mother's behavior of looking at the floor may be a cultural practice, such as avoiding direct eye contact, which should be respected. By maintaining the conversation with the mother, the nurse acknowledges and respects her communication style, fostering trust and open dialogue. Option A is not the best choice as it may disregard the cultural context and the importance of the mother's input. Option C is unnecessary as the LPN can effectively handle the situation. Option D could be perceived as insensitive and may disrupt the rapport between the nurse and the mother.

4. During an admission assessment for an older adult client, what is the priority action for the nurse after gathering data and reviewing systems?

• A. Orient the client to their room.
• B. Conduct a client care conference.
• C. Review medical prescriptions.
• D. Develop a plan of care.

Correct answer: A

Rationale: The priority action for the nurse after completing the assessment and review of systems for an older adult client is to orient them to their room. This is crucial for ensuring the client's comfort and safety in the new environment. While reviewing medical prescriptions and developing a plan of care are important aspects of the admission process, they can be done after the client has been oriented to their room.

5. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. Which device will the nurse use?

• A. Hand rolls
• B. A foot cradle
• C. A trapeze bar
• D. A trochanter roll

Correct answer: B

Rationale: A foot cradle is the correct choice for this situation. A foot cradle is used to reduce pressure on the tips of a patient's toes in individuals with poor lower extremity circulation. Hand rolls are not designed to address toe irritation specifically. A trapeze bar is used to assist patients with repositioning in bed, and a trochanter roll is used to support the hips and prevent external rotation of the legs, neither of which directly address toe irritation in this scenario.

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