Nursing Elites

1. When providing a bath, in which order will the nurse clean the body, beginning with the first area?

• A. Face
• B. Eyes
• C. Perineum
• D. Back and buttocks

Correct answer: B

Rationale: The correct sequence for giving a bath starts with cleaning the eyes, followed by the face, both arms, chest, hands/nails, abdomen, both legs, perineal hygiene, back, and finally the buttocks/anus. Therefore, the first area to be cleaned during a bath is the eyes. Choices A, C, and D are incorrect as per the standard procedure for providing a bath.

2. The nurse is caring for a client with a pressure ulcer on the sacrum. Which action should the LPN/LVN take to prevent further skin breakdown?

• A. Apply a hydrocolloid dressing to the ulcer.
• B. Reposition the client every 2 hours.
• C. Use a donut-shaped cushion when the client is sitting.
• D. Massage the area around the ulcer to promote circulation.

Correct answer: B

Rationale: Repositioning the client every 2 hours is the most appropriate action to prevent further skin breakdown in a client with a pressure ulcer on the sacrum. This practice helps relieve pressure on the affected area, promoting circulation and reducing the risk of tissue damage. Applying a hydrocolloid dressing (Choice A) may be beneficial for wound healing but is not the initial preventive measure. Using a donut-shaped cushion (Choice C) can actually increase pressure on the sacrum and worsen the condition. Massaging the area around the ulcer (Choice D) can further damage delicate skin and tissues, leading to more harm instead of prevention.

3. A healthcare professional is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care?

• A. HR 105/min
• B. BMI 25 kg/m²
• C. BP 148/92
• D. Glucose 45 mg/dL

Correct answer: D

Rationale: The correct answer is D, 'Glucose 45 mg/dL.' Glucose level of 45 mg/dL indicates hypoglycemia, which is a critical condition requiring immediate attention to prevent complications like seizures, loss of consciousness, and even coma. Hypoglycemia can lead to serious adverse outcomes if not promptly addressed. Choices A, B, and C do not represent immediate life-threatening conditions and can be managed as part of routine care, unlike hypoglycemia which demands urgent intervention.

4. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to

• A. Change whichever item is incorrect to the correct information
• B. Use the bracelet and admission form until a replacement is supplied
• C. Notify the admissions office and wait to apply the bracelet
• D. Make a corrected identification bracelet for the client

Correct answer: C

Rationale: The nurse should notify the admissions office and wait to apply the bracelet. By doing so, the nurse ensures patient safety and accuracy in identification. Changing the incorrect item (Choice A) could lead to errors and confusion in the patient's identification. Using the mismatched items until a replacement is supplied (Choice B) compromises patient safety and could result in errors during care delivery. Making a corrected identification bracelet without verifying the correct information (Choice D) could introduce further inaccuracies and risks in patient identification.

5. A client with diabetes mellitus is being taught by a nurse about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should roll the NPH vial between my hands before drawing it up.
• B. I should draw up the NPH insulin before the regular insulin.
• C. I should inject air into the vial of regular insulin first.
• D. I should wait 10 minutes after mixing the insulin to inject it.

Correct answer: A

Rationale: The correct answer is A. Rolling the NPH vial between the hands before drawing it up ensures proper mixing of the insulin. Choice B is incorrect because regular insulin should be drawn up first to avoid contamination. Choice C is incorrect as injecting air into the vial of regular insulin is not necessary. Choice D is incorrect as there is no need to wait 10 minutes after mixing the insulin before injecting it.

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