Nursing Elites

1. A healthcare professional is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the healthcare professional to take?

• A. Hold the suction catheter with the non-dominant hand.
• B. Apply suctioning for 20 to 30 seconds.
• C. Place the catheter in a clean and dry location for later use.
• D. Use surgical asepsis when performing the procedure.

Correct answer: D

Rationale: Using surgical asepsis when performing nasal tracheal suctioning is crucial to prevent infection. Choice A is incorrect because the suction catheter should be held with the dominant hand to ensure better control and precision during the procedure. Choice B is incorrect as suctioning should be applied for no longer than 10 to 15 seconds to avoid trauma to the mucous membranes. Choice C is incorrect as the catheter should be disposed of properly after single-use to prevent cross-contamination and infection.

2. The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the LPN/LVN administer?

• A. 0.5 ml
• B. 1 ml
• C. 1.5 ml
• D. 2 ml

Correct answer: A

Rationale: To administer 4 mg of morphine, as prescribed, the LPN/LVN needs to calculate the correct volume based on the concentration provided (8 mg per ml). Since the desired dose is 4 mg, half of 8 mg (0.5 ml) is required to administer the correct amount. Therefore, the correct answer is 0.5 ml. Choices B, C, and D are incorrect as they would either underdose or overdose the patient.

3. A 2-year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?

• A. Place the child on clear liquids and gelatin for 24 hours
• B. Continue with the regular diet and include oral rehydration fluids
• C. Give bananas, apples, rice, and toast as tolerated
• D. Place NPO for 24 hours, then rehydrate with milk and water

Correct answer: B

Rationale: In managing mild diarrhea in a 2-year-old child, it is important to maintain their regular diet and include oral rehydration fluids. Choice A of placing the child on clear liquids and gelatin for 24 hours may not provide adequate nutrition and can lead to further electrolyte imbalances. Choice C of giving bananas, apples, rice, and toast as tolerated is a part of the BRAT diet, which is not recommended as the primary approach anymore due to its limited nutritional value. Choice D of placing the child NPO for 24 hours and then rehydrating with milk and water is not appropriate as it can worsen dehydration and delay recovery. Therefore, the best option is to continue the child's regular diet while incorporating oral rehydration fluids to prevent dehydration and maintain nutritional status.

4. A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?

• A. A nurse tied a client's restraints straps to the moveable part of the bed frame.
• B. An assistive personnel placed a surgical mask on a client who has TB before transporting her to radiology.
• C. A nurse administered a medication to a client 30 minutes before the dose is due.
• D. A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

Correct answer: C

Rationale: The correct answer is C. An incident report should be completed when a nurse administers medication to a client significantly earlier than the scheduled time. This deviation from the prescribed schedule could potentially impact the client's treatment plan and requires documentation for proper evaluation and follow-up. Choices A, B, and D do not necessarily require an incident report. Choice A involves improper restraint application, which is a safety issue but does not directly involve medication administration. Choice B involves a protective measure for a client with TB, which is within the scope of practice for assistive personnel. Choice D describes an increase in IV fluid administration, which may need monitoring but does not necessarily indicate a need for an incident report unless there are specific complications or adverse effects related to the additional fluid.

5. What intervention can help prevent atelectasis and pneumonia in a client with amyotrophic lateral sclerosis?

• A. Active and passive range of motion exercises twice a day
• B. Every 4 hours incentive spirometer
• C. Chest physiotherapy twice a day
• D. Repositioning every 2 hours around the clock

Correct answer: C

Rationale: Chest physiotherapy is essential for clients with amyotrophic lateral sclerosis (ALS) to prevent atelectasis and pneumonia. Chest physiotherapy aids in clearing secretions, maintaining lung function, and preventing respiratory complications. Active and passive range of motion exercises (Choice A) are important for maintaining joint mobility but are not directly associated with preventing atelectasis and pneumonia in ALS. Incentive spirometer use every 4 hours (Choice B) is beneficial for lung expansion and preventing atelectasis but may not be as effective as chest physiotherapy in managing secretions. Repositioning every 2 hours (Choice D) is crucial for preventing pressure ulcers but is not directly related to preventing atelectasis and pneumonia in ALS.

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