Nursing Elites

1. During preoperative education, a nurse should assess a client's readiness to learn before a mastectomy. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

• A. “I don’t want my spouse to see my incision.”
• B. “Will you give me pain medicine after the surgery?”
• C. “Can you tell me about how long the surgery will take?”
• D. “My roommate listens to everything I say.”

Correct answer: C

Rationale: The correct answer is C. Asking about the duration of the surgery indicates readiness to learn about the procedure. This question shows that the client is actively seeking information about the surgical process, demonstrating readiness to learn. Choices A, B, and D reflect concerns, specific requests, or statements unrelated to the learning process. They do not directly indicate readiness to absorb information about the upcoming mastectomy.

2. 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.

3. A client with chronic kidney disease is receiving epoetin alfa (Epogen). Which laboratory value should the LPN/LVN monitor to determine the effectiveness of this medication?

• A. Serum potassium
• B. Hemoglobin
• C. Serum creatinine
• D. Blood urea nitrogen (BUN)

Correct answer: B

Rationale: The correct answer is B: Hemoglobin. Monitoring hemoglobin levels is essential to assess the effectiveness of epoetin alfa in clients with chronic kidney disease. Epoetin alfa is a medication that stimulates red blood cell production, aiming to increase hemoglobin levels and improve symptoms of anemia in these patients. Monitoring serum potassium (Choice A) is important in clients with kidney disease, but it is more related to assessing electrolyte balance rather than the direct effectiveness of epoetin alfa. Serum creatinine (Choice C) and blood urea nitrogen (Choice D) are kidney function tests that help evaluate kidney health but do not specifically reflect the effectiveness of epoetin alfa therapy.

4. A child is injured on the school playground and appears to have a fractured leg. What action should the school nurse take first?

• A. Call for emergency transport to the hospital
• B. Immobilize the limb and joints above and below the injury
• C. Assess the child and the extent of the injury
• D. Apply cold compresses to the injured area

Correct answer: C

Rationale: The correct first action for the school nurse to take when a child is injured and appears to have a fractured leg is to assess the child and the extent of the injury. This initial assessment is crucial to determine the severity of the injury before proceeding with further interventions. Option A, calling for emergency transport, should only be done after assessing the extent of the injury. Option B, immobilizing the limb and joints, is important but should come after the initial assessment. Option D, applying cold compresses, is not recommended for suspected fractures as it can exacerbate swelling and pain.

5. A client with a history of falls is under the care of a nurse. Which of the following actions should the nurse take to prevent falls?

• A. Keep the client's bed in the lowest position.
• B. Encourage the client to wear non-slip socks.
• C. Place a fall risk sign on the client's door.
• D. Use a gait belt when ambulating the client.

Correct answer: A

Rationale: Keeping the client's bed in the lowest position is an essential measure to prevent falls. Lowering the bed reduces the risk of injury if the client falls out of bed by decreasing the distance of the fall. Encouraging the client to wear non-slip socks (Choice B) may help prevent slips on smooth surfaces but does not address the risk of falls in other scenarios. Placing a fall risk sign on the client's door (Choice C) alone does not actively prevent falls but serves as a warning. Using a gait belt when ambulating the client (Choice D) is important for assisting with mobility but does not directly address fall prevention in the client's environment.

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