Nursing Elites

1. A healthcare provider is preparing to perform mouth care for an unresponsive client. Which of the following actions should the healthcare provider plan to take?

• A. Raise the level of the bed
• B. Administer mouth care with the client in a supine position
• C. Use a tongue depressor to open the mouth
• D. Place the client in a prone position

Correct answer: A

Rationale: Raising the bed level is the correct action to facilitate easier access for mouth care in an unresponsive client. This position enhances the safety and comfort of both the client and the healthcare provider. Administering mouth care with the client in a supine position (lying flat on their back) can increase the risk of aspiration. Using a tongue depressor to open the mouth is not recommended as it can cause discomfort and potential injury. Placing the client in a prone position (lying face down) is contraindicated for mouth care and can compromise the client's airway.

2. The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?

• A. Swelling and redness in the affected leg
• B. Pain in the affected leg
• C. Warmth and tenderness in the affected leg
• D. A positive Homans' sign

Correct answer: D

Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.

3. A client with a history of hypertension is prescribed a low-sodium diet. Which food should the LPN/LVN recommend the client avoid?

• A. Fresh fruits
• B. Grilled chicken
• C. Whole grain bread
• D. Canned soup

Correct answer: D

Rationale: The correct answer is D, canned soup. Canned soups are often high in sodium content, which can be harmful to individuals with hypertension following a low-sodium diet. Fresh fruits, grilled chicken, and whole grain bread are generally healthier options with lower sodium content and can be included in a low-sodium diet. Fresh fruits provide essential vitamins and minerals, grilled chicken is a lean protein source, and whole grain bread offers fiber and nutrients without excessive sodium levels. Avoiding canned soup aligns with the goal of reducing sodium intake to manage hypertension.

4. A client has just returned from surgery with an indwelling urinary catheter in place. What is the most important action for the nurse to take to prevent infection?

• A. Change the catheter every 72 hours.
• B. Ensure the catheter tubing is free of kinks.
• C. Clean the perineal area with antiseptic solution daily.
• D. Irrigate the catheter with normal saline every shift.

Correct answer: B

Rationale: The most crucial action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. Kinks in the tubing can lead to urine retention or obstruction, increasing the risk of infection. Changing the catheter every 72 hours is not necessary if there are no signs of infection or other issues. Cleaning the perineal area with antiseptic solution daily is important for hygiene but not the most critical action to prevent infection related to the catheter. Irrigating the catheter with normal saline every shift is not a routine practice and may increase the risk of introducing pathogens into the urinary system.

5. The client is advised to take dexamethasone (Decadron) with food or milk. What is the physiological basis for this advice?

• A. Inhibits pepsin production
• B. Stimulates hydrochloric acid production
• C. Delays stomach emptying time
• D. Reduces hydrochloric acid production

Correct answer: B

Rationale: The correct answer is B: Stimulates hydrochloric acid production. Dexamethasone can stimulate the production of hydrochloric acid in the stomach, which may lead to irritation of the stomach lining. Taking dexamethasone with food or milk helps to neutralize or buffer the acid, reducing the risk of stomach irritation. Choice A is incorrect because dexamethasone does not inhibit pepsin production. Choice C is incorrect as dexamethasone does not slow stomach emptying time. Choice D is incorrect as dexamethasone does not reduce hydrochloric acid production.

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