Nursing Elites

1. A nurse is teaching about foot care to a client who has diabetes mellitus (DM). What statement indicates understanding?

• A. I should wear my slippers whenever I am out of bed
• B. I can walk barefoot at home
• C. I should apply lotion between my toes
• D. I can soak my feet in warm water

Correct answer: A

Rationale: The correct answer is A. Wearing slippers or shoes when out of bed is crucial for clients with diabetes as it protects the feet from injury. Walking barefoot, as mentioned in option B, can increase the risk of cuts, sores, and infections in diabetic patients. Applying lotion between the toes, as stated in option C, can lead to maceration and increase the risk of fungal infections. Similarly, soaking feet in warm water, as mentioned in option D, can cause skin breakdown and should be avoided by diabetic patients.

2. A charge nurse is making assignments for the upcoming shift. What assignment should the charge nurse give to an LPN?

• A. A client who requires complex medication management
• B. A client who has dehydration and inflammatory bowel disease (IBD)
• C. A client needing assessment of a new diagnosis
• D. A client requiring a nursing care plan update

Correct answer: B

Rationale: The correct assignment for an LPN would be a client who has dehydration and inflammatory bowel disease (IBD). This choice is appropriate because it involves monitoring the client's condition, providing basic care, and assisting with activities of daily living, which align with the scope of practice for LPNs. Choices A, C, and D involve tasks that are more complex and require a higher level of nursing education and training, making them less suitable for an LPN.

3. A nurse is preparing a client for transfer to another unit. Which finding should the nurse include in the transfer report?

• A. Response to pain medication
• B. Review of ongoing discharge plan
• C. Recent physical changes
• D. All of the above

Correct answer: D

Rationale: When preparing a client for transfer to another unit, the nurse should include all the findings mentioned in the choices in the transfer report. It is crucial to document the client's response to pain medication as it helps the receiving unit manage the client's pain effectively. Reviewing the ongoing discharge plan ensures that the client's care continues seamlessly after the transfer. Noting recent physical changes is vital for the receiving unit to monitor the client's condition accurately. Therefore, all of the above findings are essential for ensuring continuity of care and providing comprehensive information to the receiving unit.

4. A nurse is preparing to administer 1 unit of packed RBCs to a client. Which of the following findings should cause the nurse to delay the transfusion?

• A. Blood pressure 140/90 mm Hg
• B. Urine output of 40 mL/hr
• C. Temperature 38.2°C (100.8°F)
• D. Hemoglobin 8 g/dL

Correct answer: C

Rationale: A temperature of 38.2°C (100.8°F) suggests the possibility of an underlying infection or fever, which should be evaluated before proceeding with the transfusion to prevent complications. Elevated temperature can indicate an immune response to incompatible blood components, increasing the risk of a transfusion reaction. The other vital signs and lab results provided are within acceptable ranges for administering packed RBCs, making choices A, B, and D less likely to cause a delay in the transfusion.

5. A nurse is preparing to perform a sterile dressing change for a client with a surgical wound. Which action should the nurse take to prevent contamination during the dressing change?

• A. Proceed with the dressing change
• B. Restart the procedure if the sterile solution splashes onto the sterile field
• C. Continue without concern for minor splashes
• D. Delegate the task to another nurse

Correct answer: B

Rationale: The correct action for the nurse to take to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field. Any contamination of the sterile field compromises the aseptic technique and increases the risk of infection for the client. Therefore, it is crucial to maintain the sterility of the field throughout the procedure. Choices A, C, and D are incorrect because proceeding with the dressing change, continuing without concern for minor splashes, or delegating the task to another nurse would all compromise the sterility of the procedure and increase the risk of infection for the client.

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