Nursing Elites

1. A nurse is planning client assignments for the day. Which task should the nurse assign to the nursing assistant (unlicensed assistive personnel)?

• A. Recording the urinary output for a client with renal calculi whose urine must be strained
• B. Dressing change instructions for a client who had a mastectomy 2 days ago
• C. Reporting abnormal lab values to the health care provider for a client scheduled for a laparoscopic cholecystectomy
• D. Preprocedural teaching for a client scheduled for a cardiac stress test

Correct answer: A

Rationale: The nurse is legally responsible for client assignments and must assign tasks based on state nursing practice act guidelines and job descriptions provided by the employing agency. The nursing assistant is trained to measure, collect, and strain urine, making recording urinary output for a client with renal calculi a suitable task for the nursing assistant. This task falls within the nursing assistant's role description. Dressing change instructions for a client who had a mastectomy involve a higher level of skill and knowledge, beyond the scope of a nursing assistant. Reporting abnormal lab values to the health care provider for a client scheduled for a laparoscopic cholecystectomy requires interpretation and clinical judgment, which is typically not within the nursing assistant's role. Preprocedural teaching for a client scheduled for a cardiac stress test involves providing detailed information and education, which is usually the responsibility of a licensed nurse or other qualified healthcare provider.

2. How does cancer affect pain tolerance in elderly clients?

• A. Remain constant.
• B. Decrease.
• C. Increase.
• D. Cancer has no impact on pain tolerance in elderly clients.

Correct answer: B

Rationale: Pain tolerance in elderly clients with cancer is likely to decrease due to factors such as diminished adaptative capacity, increased physical discomfort, and the psychological impact of the disease. Cancer is known to cause various physical and emotional stressors that can lower the pain threshold, leading to a decrease in pain tolerance. Choices A, C, and D are incorrect because cancer and its associated effects typically result in a decrease in pain tolerance rather than remaining constant, increasing, or having no impact.

3. The ICU nurse caring for a client who has just been declared brain dead can expect to find evidence of the client's wishes regarding organ donation:

• A. on the client's driver's license.
• B. in the client's safety deposit box.
• C. in the client's last will and testament.
• D. on the client's insurance card.

Correct answer: A

Rationale: In most states, indication of organ donor status is found on the client's driver's license, making it easily accessible for decision-making in critical situations like declaring brain death. Evidence in a last will and testament or a safety deposit box may not be promptly available. Information about organ donation is typically not included on insurance cards. The primary care physician's health record documentation could also be a relevant source for the ICU nurse. Therefore, the correct answer is finding evidence of the client's wishes regarding organ donation on the client's driver's license.

4. To what does legal protection of confidentiality extend?

• A. Written documentation only.
• B. Electronic dissemination of information not identifiable to a specific client.
• C. Only within the court system.
• D. Both written and verbal information.

Correct answer: D

Rationale: Legal protection of confidentiality extends to both written and verbal information that is identifiable as individual private health information. Confidentiality in healthcare settings is vital to protect patients' privacy and trust. Choice A is incorrect because legal protection covers verbal information as well, not just written documentation. Choice B is incorrect as it mentions information not identifiable to a specific client, which wouldn't fall under legal protection of confidentiality. Choice C is incorrect as confidentiality extends beyond just the court system, impacting various healthcare settings and interactions. Therefore, the correct answer is D.

5. How should the LPN document pain for a non-verbal client using the FLACC pain scale with these findings?

• A. 1
• B. 4
• C. 3
• D. 2

Correct answer: B

Rationale: The correct answer is B: '4'. The FLACC pain scale assesses pain in non-verbal patients based on five categories: Face, Legs, Activity, Cry, and Consolability. In this case, the client exhibits occasional grimacing (1 point), relaxed legs (0 points), squirming (1 point), moans and whimpers (1 point), and is distractible (1 point). Adding these points together results in a total pain score of 4. Therefore, the LPN should document a pain score of 4 for this non-verbal client. Choices A, C, and D are incorrect as they do not accurately reflect the total pain score based on the given findings.

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