Nursing Elites

1. A client is being taught about the use of an incentive spirometer. Which statement by the client indicates effective teaching?

• A. I will use the spirometer every hour while awake.
• B. I will blow into the spirometer as hard as I can.
• C. I should feel dizzy when using the spirometer.
• D. I will only use the spirometer if I feel short of breath.

Correct answer: A

Rationale: The correct answer is A because using the spirometer every hour while awake is an effective way to prevent respiratory complications. This frequency helps in maintaining lung function and preventing atelectasis. Choice B is incorrect because blowing too hard into the spirometer can lead to hyperventilation and dizziness, making choice C also incorrect. Choice D is wrong as waiting to use the spirometer only when feeling short of breath may not provide optimal lung expansion and can lead to respiratory issues.

2. A client with a history of hypertension is taking a beta-blocker. Which side effect should the LPN/LVN monitor for in this client?

• A. Increased appetite
• B. Dry mouth
• C. Bradycardia
• D. Insomnia

Correct answer: C

Rationale: The correct answer is C: Bradycardia. Beta-blockers are medications that can lower heart rate, leading to bradycardia as a potential side effect. It is essential for the LPN/LVN to monitor for this adverse effect due to the medication's mechanism of action. Choices A, B, and D are incorrect because increased appetite, dry mouth, and insomnia are not typically associated with beta-blocker use. Monitoring for bradycardia is crucial to ensure patient safety and to prevent any potential complications.

3. The nurse is caring for an older adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?

• A. Encourage the patient to perform as many self-care activities as possible.
• B. Provide assistance with a bed bath to promote patient comfort.
• C. Coordinate with physical therapy for gait training.
• D. Instruct the patient to remain on bed rest to prevent fatigue.

Correct answer: A

Rationale: The correct answer is A: Encourage the patient to perform as many self-care activities as possible. For a patient who has had a stroke, promoting independence and engaging in self-care activities help maintain mobility and foster a sense of autonomy. Choices B, C, and D are incorrect because providing assistance with a bed bath, coordinating with physical therapy for gait training, or advising bed rest without indications may not be the best interventions for promoting optimal recovery and independence in a stroke patient.

4. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?

• A. Loosen the right wrist restraint.
• B. Apply a pulse oximeter to the right hand.
• C. Compare hand color bilaterally.
• D. Palpate the right radial pulse.

Correct answer: A

Rationale: The correct action to take first when observing blue fingers in a client with wrist restraints is to loosen the right wrist restraint. Blue fingers indicate compromised circulation, and loosening the restraint can help restore blood flow to the area. Applying a pulse oximeter (Choice B) or palpating the right radial pulse (Choice D) may be necessary following the loosening of the restraint to assess the client's oxygen saturation and pulse. Comparing hand color bilaterally (Choice C) is important but not the immediate action needed when a circulation issue is noted in one hand.

5. 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.

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