Nursing Elites

1. A client is immobile due to a cast, and a nurse is assisting in the use of a fracture bedpan. Which of the following actions should the nurse take?

• A. Place the shallow end of the fracture pan under the client’s buttocks.
• B. Encourage the client to remain immobile on the fracture pan for 20 minutes.
• C. Keep the bed flat while the client is on the fracture pan.
• D. Hyperextend the client’s back while the fracture pan is in place.

Correct answer: A

Rationale: The correct action when using a fracture bedpan for an immobile client is to place the shallow end of the pan under the client's buttocks. This positioning helps in proper collection of feces without causing discomfort or injury. Encouraging the client to try to defecate for 20 minutes (Choice B) is inappropriate and unrealistic, as defecation should not be forced or timed. Keeping the bed flat (Choice C) is incorrect as elevating the head of the bed can help promote proper positioning for bedpan use. Hyperextending the client's back (Choice D) is contraindicated and can lead to discomfort and potential injury to the client.

2. A 10-year-old client is recovering from a splenectomy following a traumatic injury. The client's laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to:

• A. Limit milk and milk products
• B. Encourage bed rest and quiet activities
• C. Plan nursing care around lengthy rest periods
• D. Promote a diet rich in iron

Correct answer: C

Rationale: Encouraging bed rest and quiet activities is crucial for a child recovering from a splenectomy with low hemoglobin and hematocrit levels. This approach helps conserve energy, promotes healing, and allows the body to focus on rebuilding red blood cells. Limiting milk and milk products (Choice A) is not directly related to improving the child's condition. Encouraging bed rest and quiet activities (Choice B) is appropriate as it helps in conserving energy and preventing physical exertion. Promoting a diet rich in iron (Choice D) is beneficial for improving hemoglobin levels in the long term, but immediate rest and recovery take precedence in this scenario.

3. Which goal is most appropriate for a patient who has had a total hip replacement?

• A. The patient will ambulate briskly on the treadmill by the time of discharge.
• B. The patient will walk 100 feet using a walker by the time of discharge.
• C. The nurse will assist the patient to ambulate in the hall 2 times a day.
• D. The patient will ambulate by the time of discharge.

Correct answer: B

Rationale: The goal 'The patient will walk 100 feet using a walker by the time of discharge' is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, achievable, and individualized. This goal sets a clear target for the patient's mobility progress post-surgery. Choice A is too vague and does not provide a specific target distance or method of ambulation. Choice C focuses on the nurse's actions rather than the patient's progress. Choice D lacks specificity in terms of distance or assistance required, making it less measurable and individualized compared to Choice B.

4. An 18-year-old client is admitted to the intensive care unit from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebra. The nurse's priority assessment should be

• A. Response to stimuli
• B. Bladder control
• C. Respiratory function
• D. Muscle strength

Correct answer: C

Rationale: Injuries at the level of the 2nd cervical vertebra can affect the phrenic nerve, leading to potential impairment of respiratory function. Assessing respiratory function is crucial as compromised breathing can quickly escalate to life-threatening situations. While response to stimuli is important, ensuring adequate oxygenation takes precedence due to the immediate threat to life. Bladder control may be affected by spinal cord injuries at higher levels, but it is not the priority in this scenario. Muscle strength is a potential consequence of cervical spinal cord injury, but assessing respiratory function is more critical in the acute phase.

5. A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the LPN/LVN set the client's intravenous infusion pump?

• A. 13 ml/hour
• B. 63 ml/hour
• C. 80 ml/hour
• D. 125 ml/hour

Correct answer: B

Rationale: To calculate the correct rate of infusion, divide the total volume by the total time: 250 ml / 4 hours = 62.5 ml/hour, which is rounded up to 63 ml/hour. This rate ensures the proper administration of the KCl over the 4-hour period. Choice A (13 ml/hour) is incorrect as it does not match the calculated rate. Choices C (80 ml/hour) and D (125 ml/hour) are also incorrect as they do not correspond to the calculated rate needed for the specified time frame.

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