Nursing Elites

1. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?

• A. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
• B. Pinch the skin on the back of the hand and observe for elasticity
• C. Assess the skin turgor on the abdomen by pinching the skin
• D. Check the skin turgor by pressing on the forearm and observing the rebound

Correct answer: A

Rationale: To assess skin turgor, the nurse should grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. This method is preferred for older adults and in cases of significant fluid imbalance. Option B is incorrect as assessing skin turgor on the back of the hand is not the standard assessment site for skin turgor. Option C is incorrect as the abdomen is not the typical area for assessing skin turgor; the chest under the clavicle is a more accurate site. Option D is incorrect as pressing on the forearm is not the appropriate site for evaluating skin turgor; the chest under the clavicle is the recommended location for this assessment.

2. A healthcare provider is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the healthcare provider plan to take?

• A. Place the client in Trendelenburg's position.
• B. Position the client in an upright sitting position.
• C. Administer bronchodilators after the procedure.
• D. Perform chest percussion and vibration while the client is lying flat.

Correct answer: A

Rationale: Placing the client in Trendelenburg's position is the appropriate action when providing chest physiotherapy for a client with left lower lobe atelectasis. This position helps mobilize secretions from the lower lobes of the lungs, aiding in their clearance. Trendelenburg's position promotes drainage from the affected area. Positioning the client in an upright sitting position (Choice B) would not facilitate the drainage of secretions from the affected lobe. Administering bronchodilators after the procedure (Choice C) is not directly related to chest physiotherapy and the treatment of atelectasis. Performing chest percussion and vibration while the client is lying flat (Choice D) may not effectively target the lower lobes where the atelectasis is located.

3. A nurse has an order to remove sutures from a client. After retrieving the suture removal kit and applying sterile gloves, which of the following actions should the nurse take next?

• A. Clean sutures along the incision site.
• B. Remove sutures using sterile technique.
• C. Inspect the wound for signs of infection.
• D. Document the removal of sutures.

Correct answer: B

Rationale: After applying sterile gloves, the nurse should proceed to remove the sutures using sterile technique. This step ensures the safe and effective removal of sutures without introducing infection. Choice A, cleaning sutures along the incision site, would not be the next step as the primary focus is on suture removal. Inspecting the wound for signs of infection (Choice C) is important but typically follows suture removal. Documenting the removal of sutures (Choice D) is essential but usually occurs after the procedure is completed.

4. A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge?

• A. Asks relevant questions regarding the dressing change.
• B. States he will be able to complete the wound care regimen.
• C. Demonstrates the wound care procedure correctly.
• D. Has all the necessary supplies for wound care.

Correct answer: C

Rationale: The correct answer is C. Demonstrating the wound care procedure correctly indicates the client's readiness to independently manage wound care. This action shows practical understanding and application of the necessary skills. Choice A, asking relevant questions, is important but does not directly demonstrate the ability to perform the procedure. Choice B, stating the ability to complete the regimen, is a good intention but does not confirm practical competence. Choice D, having necessary supplies, is essential but does not ensure the client's ability to execute proper wound care.

5. The healthcare professional is preparing to administer an intramuscular injection to an adult client. Which site is most appropriate for the LPN/LVN to use?

• A. Deltoid muscle
• B. Ventrogluteal site
• C. Dorsogluteal site
• D. Rectus femoris site

Correct answer: B

Rationale: The ventrogluteal site is the most appropriate and safest site for administering an intramuscular injection to an adult client. It is preferred due to its thick muscle mass and fewer major blood vessels and nerves in the area, reducing the risk of injury or complications. The deltoid muscle is commonly used for vaccines and small-volume injections but may not be suitable for larger volumes. The dorsogluteal site has fallen out of favor due to the risk of injury to the sciatic nerve and other underlying structures. The rectus femoris site is not typically used for intramuscular injections in adults.

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