Nursing Elites

1. While caring for a client who, while sitting in a chair, starts to experience a seizure, what action should the nurse take?

• A. Lower the client to the floor and place a pad under the client's head.
• B. Hold the client's head still to prevent injury.
• C. Restrain the client to prevent movement.
• D. Place the client in a supine position.

Correct answer: A

Rationale: During a seizure, the priority is to lower the client to the floor to prevent injury and ensure their safety. Placing a pad under the client's head helps protect the head from injury. Choice B, holding the client's head still, is incorrect as it can lead to harm; it's essential to allow movement during a seizure to prevent neck injury. Choice C, restraining the client, is dangerous and can cause harm by restricting movement. Choice D, placing the client in a supine position, is also not recommended during a seizure as it does not provide adequate protection for the client.

2. A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines?

• A. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse.
• B. A nurse asks a nurse from another unit to assist with her documentation.
• C. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care.
• D. A nurse discusses a client's status with the physical therapist who is caring for the client at the bedside.

Correct answer: B

Rationale: The correct answer is B. HIPAA guidelines specify that only healthcare professionals directly involved in a patient's care should access their medical information. Asking a nurse from another unit to assist with documentation involves sharing patient information with someone not directly caring for the patient, which violates HIPAA guidelines. Choices A, C, and D involve individuals directly involved in the client's care, making them appropriate actions in line with HIPAA regulations. Choice A involves educating a nursing student under the supervision of the nurse, which is permissible. Choice C involves communicating with the client's designated healthcare decision-maker, which is also allowed under HIPAA. Choice D involves discussing the client's status with another healthcare professional directly involved in the client's care, which is within HIPAA guidelines.

3. The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next?

• A. Insert an oral airway.
• B. Place the patient in a flat, supine position.
• C. Use undiluted hydrogen peroxide as a cleaner.
• D. Quickly proceed without talking to the patient.

Correct answer: A

Rationale: When a debilitated patient resists oral hygiene, the nurse should prioritize safety. Inserting an oral airway helps keep the mouth open, ensuring adequate access for oral care procedures while preventing any accidental biting or closure of the airway. Placing the patient in a flat, supine position may not address the resistance issue and can lead to aspiration risk. Using undiluted hydrogen peroxide is not recommended due to its potential harmful effects on oral tissues. Proceeding quickly without communication can escalate the situation and compromise patient-centered care.

4. The nurse is caring for a client with diabetes insipidus. Which finding should the LPN/LVN report to the healthcare provider?

• A. Weight gain
• B. Increased urine output
• C. Low blood pressure
• D. Thirst

Correct answer: B

Rationale: The correct answer is B: Increased urine output. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large amounts of dilute urine. Reporting increased urine output is crucial as it is a hallmark sign of diabetes insipidus. Weight gain (choice A) is not typically associated with diabetes insipidus; instead, clients may experience weight loss due to fluid loss. Low blood pressure (choice C) can be a complication of diabetes insipidus due to dehydration from excessive urination, but the priority finding to report is the increased urine output. Thirst (choice D) is a common symptom of diabetes insipidus due to the body's attempt to compensate for fluid loss, but it is not the most critical finding to report.

5. What intervention should be implemented by the LPN to reduce the risk of aspiration in a client with a nasogastric tube receiving continuous enteral feedings?

• A. Elevate the head of the bed to 30-45 degrees.
• B. Check residual volumes every 4 hours.
• C. Verify tube placement every shift.
• D. Flush the tube with water every 4 hours.

Correct answer: A

Rationale: Elevating the head of the bed to 30-45 degrees is crucial in reducing the risk of aspiration because it helps keep the gastric contents lower than the esophagus, thereby promoting proper digestion and preventing reflux. This position also aids in reducing the likelihood of regurgitation and aspiration of gastric contents. Checking residual volumes every 4 hours is important for monitoring feeding tolerance but does not directly address the risk of aspiration. Verifying tube placement every shift is essential for ensuring the tube is correctly positioned within the gastrointestinal tract but does not directly reduce the risk of aspiration. Flushing the tube with water every 4 hours may help maintain tube patency and prevent clogging, but it does not specifically address the risk of aspiration associated with nasogastric tube feedings.

Similar Questions