Nursing Elites

1. While providing care to a group of patients, which patient should the nurse prioritize seeing first?

• A. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
• B. A bedridden patient with a reddened area on the buttocks who needs to be turned
• C. A patient on bed rest with renal calculi who needs to go to the bathroom
• D. A patient post-knee surgery who needs range of motion exercises

Correct answer: A

Rationale: The nurse should prioritize seeing the patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea first. This patient is at higher risk for deep vein thrombosis due to prolonged bed rest, which can lead to a life-threatening embolus. Chest pain and dyspnea could also indicate a potential pulmonary embolism, which requires immediate assessment and intervention. The other patients, while requiring care, do not present with symptoms that suggest an immediate life-threatening situation, making them lower priority at this time. Therefore, option A is the correct choice as it addresses a potentially critical condition that requires immediate attention.

2. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

• A. The AP hangs the collection bag below the level of the bladder.
• B. The AP performs hand hygiene before handling the catheter.
• C. The AP secures the catheter to the client’s leg with tape.
• D. The AP empties the collection bag when it is full.

Correct answer: A

Rationale: Hanging the collection bag below the level of the bladder is the correct technique for maintaining proper drainage and preventing backflow in a client with an indwelling urinary catheter. Therefore, choice A is the correct answer as it indicates a need for further teaching. Choices B, C, and D demonstrate appropriate actions in catheter care. Performing hand hygiene before handling the catheter helps prevent infection, securing the catheter to the client’s leg with tape prevents accidental dislodgement, and emptying the collection bag when it is full ensures that the catheter functions effectively.

3. A healthcare professional reviewing a client’s health record notes a new prescription for lisinopril 10 mg PO once daily. The healthcare professional should identify this as which of the following types of prescription?

• A. Single
• B. Stat
• C. Routine
• D. Now

Correct answer: C

Rationale: A prescription for once-daily medication is considered routine as it is meant for regular, daily administration to maintain therapeutic levels in the body. Single prescriptions are for one-time use only. Stat prescriptions are for immediate administration in urgent situations, while now prescriptions are also for immediate use but may have varying levels of urgency depending on the patient's condition. In this case, since the prescription is for once daily use, it falls under the category of routine prescription.

4. A client is being taught how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client’s motivation to learn?

• A. The client’s belief that his needs will be met through education
• B. The nurse’s empathy regarding the client's self-injection
• C. The client seeking family approval by agreeing to a teaching plan
• D. The nurse explaining the need for education to the client

Correct answer: A

Rationale: The client's belief that his needs will be met through education is the most likely factor to increase motivation to learn. When individuals perceive that their educational efforts will directly benefit them, they are more motivated to engage in the learning process. Empathy from the nurse, seeking family approval, or the nurse explaining the need for education may not be as directly tied to the client's personal benefit and may not necessarily increase motivation to learn.

5. A client with a history of seizures is prescribed phenytoin (Dilantin). Which statement should the LPN/LVN include when teaching the client about this medication?

• A. Do not take the medication with milk to avoid reduced absorption.
• B. Brush and floss your teeth regularly to prevent gum disease.
• C. Avoid taking antacids within 2 hours of the medication.
• D. Report any unusual bleeding or bruising to the healthcare provider.

Correct answer: C

Rationale: The correct answer is to avoid taking antacids within 2 hours of phenytoin. Antacids can interfere with the absorption of phenytoin, reducing its effectiveness. Choice A is incorrect because phenytoin should not be taken with milk, as it may decrease its absorption. Choice B is unrelated to the medication and focuses on dental hygiene. Choice D is important but not directly related to phenytoin; it is more relevant to monitoring for adverse effects of the medication.

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