Nursing Elites

1. A caregiver is talking with the caregivers of a 10-year-old child who is concerned that their child is becoming secretive, including closing the door when showering and dressing. Which of the following responses should the caregiver make?

• A. “Perhaps you should try to find out what is happening behind those closed doors.”
• B. “Suggest that the door be left ajar for safety reasons.”
• C. “At this age, children tend to become modest and value their privacy.”
• D. “You should establish a disciplinary plan to stop this behavior.”

Correct answer: C

Rationale: The correct response is C: “At this age, children tend to become modest and value their privacy.” During the developmental stage around 10 years old, children often start to value their privacy more and exhibit behaviors like closing doors when showering or dressing. It is a normal part of growing up and developing a sense of modesty. Choice A is incorrect as it suggests prying into the child's privacy, which may be counterproductive and invasive. Choice B is not the best response as it focuses on safety but fails to address the child's developmental stage and need for privacy. Choice D is also incorrect as it advocates for discipline without recognizing the normal developmental behavior of children at this age.

2. The client with a diagnosis of chronic heart failure is receiving discharge teaching. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself every day at the same time.
• B. I will call my doctor if my legs swell more.
• C. I will take my water pill only when I feel short of breath.
• D. I will limit the amount of salt in my diet.

Correct answer: C

Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to help manage fluid retention in chronic heart failure. This statement indicates a need for further teaching as the client needs to understand the importance of consistent medication adherence. Choices A, B, and D demonstrate good understanding of self-care management in heart failure, including daily weight monitoring, prompt reporting of worsening symptoms to the healthcare provider, and dietary sodium restriction, respectively.

3. A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regime. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide?

• A. Surgery removes the disk and is the only treatment that can totally resolve the pain
• B. The medication regimen you previously used should be re-evaluated for dose adjustment
• C. Massage and hot pack treatments are less invasive and can provide temporary relief
• D. Acupuncture is a complementary therapy that is often effective for management of pain

Correct answer: D

Rationale: Acupuncture has been effective for the client previously, supporting continued use.

4. The LPN observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?

• A. Tell the UAP to use a larger cuff at the next scheduled assessment.
• B. Reassess the client's blood pressure using a larger cuff.
• C. Have the unit educator review this procedure with the UAPs.
• D. Teach the UAP the correct technique for assessing blood pressure.

Correct answer: B

Rationale: Reassessing the client's blood pressure using a larger cuff is the most important action for the nurse to implement in this situation. Using the correct cuff size is crucial for obtaining accurate blood pressure readings. By reassessing with a larger cuff, the nurse can ensure an accurate measurement and proper monitoring of the client's blood pressure. Choice A is not the best option as it doesn't address the immediate need for accurate blood pressure measurement. Choice C is not the most appropriate action at this time since the immediate concern is ensuring correct blood pressure assessment. Choice D, while important, is not the most critical step in this scenario where immediate reassessment is needed with the correct cuff size.

5. A hospitalized client needs a chest x-ray. The radiology department calls the nursing unit and says that they are sending a transporter for the client. When entering the client’s room, the priority action is to:

• A. Check the client’s identification bracelet
• B. Inform the client about the procedure
• C. Prepare the client for transport
• D. Verify the x-ray order

Correct answer: A

Rationale: The correct action to take when a transporter arrives to take a hospitalized client for a procedure is to check the client's identification bracelet. This step is crucial to prevent errors and ensure that the correct patient is receiving the intended procedure. Informing the client about the procedure and preparing them for transport are important steps in the process, but verifying the client's identity takes precedence to ensure patient safety. Verifying the x-ray order, though important, is not the priority action when the transporter arrives; confirming the patient's identity is essential before proceeding with any procedures.

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