Nursing Elites

1. A client is scheduled for a total laryngectomy. Which of the following interventions is the priority for the nurse?

• A. Schedule a support session for the client.
• B. Explain the techniques of esophageal speech.
• C. Review the use of artificial larynx with the client.
• D. Determine the client's reading ability.

Correct answer: B

Rationale: The priority intervention for a client scheduled for a total laryngectomy is to explain the techniques of esophageal speech. This is crucial for the client's post-surgery communication. Option A, scheduling a support session, is important but not the priority as ensuring the client can communicate effectively comes first. Option C, reviewing the use of artificial larynx, is relevant but not the priority compared to teaching esophageal speech. Option D, determining the client's reading ability, is not as critical as ensuring the client learns a primary method of communication following the laryngectomy.

2. 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.

3. A client with lower extremity weakness is being taught a four-point crutch gait by a nurse. Which of the following instructions should the nurse include in the teaching?

• A. Bear weight on both legs.
• B. Move the crutches and the weak leg in unison.
• C. Advance the crutches and the strong leg simultaneously.
• D. Move the crutches forward, then move one leg at a time.

Correct answer: D

Rationale: The correct technique for a four-point crutch gait involves moving the crutches forward, then moving one leg at a time. This method provides stability and support by alternating movement between the crutches and legs. Choice A is incorrect because bearing weight on both legs simultaneously is not the correct method for a four-point gait. Choice B is incorrect as moving the crutches and weak leg together does not provide the required stability. Choice C is incorrect as advancing the crutches and strong leg together does not promote the alternating movement needed for a four-point gait.

4. A client with osteoporosis is prescribed alendronate (Fosamax). What instruction should the LPN/LVN provide to the client?

• A. Take the medication with a full glass of water.
• B. Take the medication at bedtime.
• C. Take the medication with food.
• D. Take the medication on an empty stomach.

Correct answer: A

Rationale: The correct instruction for a client prescribed alendronate (Fosamax) is to take the medication with a full glass of water. Alendronate can cause irritation to the esophagus, so it is important to take it with a full glass of water and remain upright for at least 30 minutes after taking the medication to help prevent this irritation. Taking the medication at bedtime (choice B) may increase the risk of esophageal irritation as lying down can allow the medication to remain in the esophagus longer. Taking the medication with food (choice C) or on an empty stomach (choice D) can also interfere with the absorption of alendronate, reducing its effectiveness in treating osteoporosis.

5. A client reports increased pain following physical therapy. Which of the following questions should be asked to assess the quality of the pain?

• A. Is your pain sharp or dull?
• B. Is your pain constant or intermittent?
• C. On a scale from 1 to 10, how severe is your pain?
• D. Where exactly is your pain located?

Correct answer: A

Rationale: Correct Answer: A. Asking whether the pain is sharp or dull helps in determining the quality of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate chronic issues. Choices B, C, and D focus on different aspects of pain assessment. Option B pertains to the pattern of pain, either constant or intermittent. Option C addresses the severity of pain on a numerical scale. Option D inquires about the location of pain. While all these questions are essential in pain assessment, when specifically evaluating the quality of pain, distinguishing between sharp and dull sensations is crucial.

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