Nursing Elites

1. A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. Before administering the medication, the nurse must first take which action?

• A. Check the client's apical pulse
• B. Check when the last feeding was given
• C. Check the placement of the tube
• D. Check when the last medications were given

Correct answer: C

Rationale: Before administering medications through an NG tube, the nurse must first check the placement of the tube to prevent aspiration. This is done by aspirating gastric contents and measuring the pH. Checking the client's apical pulse is unrelated to NG tube medication administration. Checking when the last feeding was given is important but not a priority before administering medications. Checking when the last medications were given is also not directly related to ensuring the safe administration of medications through an NG tube. Ensuring the correct placement of the tube is crucial to prevent complications such as pulmonary aspiration.

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. A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client's advocate by undertaking which action?

• A. Reassuring the client that the risks are minimal
• B. Noting in the client's record that the client was not told about the risks of the surgery
• C. Writing a note on the front of the client's record so that the surgeon will see it when the client arrives in the operating room
• D. Informing the surgeon verbally about the lack of information provided to the client

Correct answer: B

Rationale: A nurse serves as a client advocate by protecting the client's right to be informed and to participate in decisions regarding care. In this scenario, the nurse should document in the client's record that the client was not informed about the risks of the surgery. This action ensures that the issue is officially noted and can be addressed by the healthcare team. Reassuring the client that the risks are minimal is incorrect because it dismisses the client's concerns and does not address the lack of information provided. Writing a note on the client's chart to inform the surgeon is not as effective as ensuring that the issue is officially documented in the client's record, where it can be reviewed and addressed by the healthcare team. Informing the surgeon verbally is not as reliable as documenting the concern in the client's record, which provides a formal and lasting record for review and follow-up.

4. While observing a client using crutches for a leg injury, which action would indicate a need for more education by the LPN?

• A. The client places the top padding 1-2 inches below the axilla with a firm grip on the handles.
• B. The client rests the axilla on the top padding and loosely grips the handles with hands.
• C. The client has a slight bend in the elbow when using the handles.
• D. When going down the stairs, the client leads with the injured leg.

Correct answer: B

Rationale: The correct answer is B. Resting the axilla on the top padding can cause nerve damage; instead, the client should place the top padding 1-2 inches below the axilla with a firm grip on the handles for proper support and stability while using crutches. Having a slight bend in the elbow when using the handles (choice C) is a correct technique to ensure proper weight distribution. Leading with the uninjured leg when going down the stairs (choice D) is the correct way to maintain balance and prevent further injury to the injured leg. Therefore, choice B indicates a need for more education to prevent potential nerve damage and ensure safe crutch use.

5. A nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which is the most appropriate action for the nurse to take?

• A. Report the incident to the nursing supervisor
• B. Confront the nurse who gave the enema and inform the nurse that she may face charges of battery
• C. Tell the client that the nurse did the right thing in giving the enema
• D. Contact the client's health care provider

Correct answer: A

Rationale: Battery is any intentional touching of a client without the client's consent, which violates the client's rights. If a nurse discovers such an incident, they should report it to the nursing supervisor. Confronting the nurse and threatening charges of battery could lead to unnecessary conflict. Telling the client that the nurse did the right thing is incorrect as it goes against the client's wishes. While the health care provider may need to be notified eventually, the first step should be reporting the incident to the nursing supervisor to address the violation appropriately.

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