Nursing Elites

1. A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care?

• A. Infuse hypotonic IV fluids.
• B. Implement a fluid restriction.
• C. Increase sodium intake.
• D. Administer sodium polystyrene sulfonate.

Correct answer: A

Rationale: The correct answer is to infuse hypotonic IV fluids. In hypernatremia, there is an elevated sodium concentration in the blood, and diluting it with hypotonic fluids helps to lower the sodium levels. Implementing a fluid restriction or increasing sodium intake would worsen hypernatremia by further concentrating sodium in the body. Administering sodium polystyrene sulfonate is used for treating hyperkalemia, not hypernatremia.

2. A client with a history of diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the LPN/LVN to take?

• A. Monitor the client's blood glucose level.
• B. Encourage the client to increase fluid intake.
• C. Administer insulin as prescribed.
• D. Assess the client's urine output.

Correct answer: A

Rationale: The most important action for the LPN/LVN to take when a client with a history of diabetes mellitus experiences symptoms of hyperglycemia such as polyuria, polydipsia, and polyphagia is to monitor the client's blood glucose level. This action helps assess the severity of hyperglycemia and guides further interventions. Encouraging the client to increase fluid intake (Choice B) may exacerbate the symptoms by further diluting the blood glucose concentration. Administering insulin as prescribed (Choice C) should be done based on the healthcare provider's orders and after assessing the blood glucose levels. Assessing the client's urine output (Choice D) is important but not the most immediate action needed in this scenario.

3. When conducting an admission assessment, the LPN should ask the client about the use of complementary healing practices. Which statement is accurate regarding the use of these practices?

• A. Complementary healing practices interfere with the efficacy of the medical model of treatment.
• B. Conventional medications are likely to interact with folk remedies and cause adverse effects.
• C. Many complementary healing practices can be used in conjunction with conventional practices.
• D. Conventional medical practices will ultimately replace the use of complementary healing practices.

Correct answer: C

Rationale: When considering the use of complementary healing practices, it is important to acknowledge that many of these practices can be safely integrated with conventional treatments to provide holistic care. Choice A is incorrect because complementary healing practices can complement traditional medical approaches rather than interfere with their efficacy. Choice B is incorrect as interactions between conventional medications and folk remedies may vary, but not all interactions lead to adverse effects. Choice D is incorrect as conventional medical practices and complementary healing practices can coexist and each offer benefits in healthcare.

4. During the initial physical assessment of a newly admitted client with a pressure ulcer, an LPN observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate?

• A. The nurse should have also initiated a plan to increase activity.
• B. The nurse provided supportive nursing care for the well-being of the client.
• C. Debridement of the pressure ulcer should have been performed before applying the dressing.
• D. Treatment should not have been initiated until the healthcare provider's prescriptions were received.

Correct answer: B

Rationale: The correct answer is B. Providing supportive nursing care, such as applying emollients and reinforcing the dressing on the pressure ulcer, meets the immediate needs of the client and is in line with legal and professional standards. Option A is incorrect because increasing activity may not be directly related to the immediate skin care needs of the client. Option C is incorrect as debridement might not be immediately necessary based on the initial assessment. Option D is incorrect as nurses are often authorized to initiate treatments within their scope of practice without waiting for healthcare provider prescriptions, especially for routine care like skin moisturization and dressing reinforcement.

5. A 15-year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching?

• A. I will only have to wear this for 6 months.
• B. I should inspect my skin daily.
• C. The brace will be worn day and night.
• D. I can take it off when I shower.

Correct answer: A

Rationale: The correct answer is A. The statement 'I will only have to wear this for 6 months' indicates a need for additional teaching because the Milwaukee Brace is typically worn for 12-18 months, not just 6 months. Choice B is correct as inspecting the skin daily is important to prevent skin breakdown. Choice C is correct as the brace is usually worn day and night for effectiveness. Choice D is correct as the brace can be removed when showering to maintain hygiene.

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