Nursing Elites

1. A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?

• A. “I will place the client on their side.”
• B. “I will go to the nurses’ station for assistance.”
• C. “I will note the time that the seizure begins.”
• D. “I will prepare to insert an airway.”

Correct answer: B

Rationale: The correct answer is B. Going to the nurses’ station for assistance during a seizure is inappropriate as immediate care is necessary. Placing the client on their side helps maintain an open airway and prevents aspiration. Noting the time the seizure begins is crucial for monitoring and documentation. Preparing to insert an airway may be necessary if the client's airway becomes compromised. Therefore, the nurse's statement about going to the nurses' station for assistance is the only incorrect response as it delays essential care.

2. While auscultating the anterior chest of a client newly admitted to a medical-surgical unit, a nurse listens to the audio clip of breath sounds through her stethoscope. What type of breath sounds does the nurse hear?

• A. Crackles
• B. Rhonchi
• C. Friction rub
• D. Normal breath sounds

Correct answer: D

Rationale: The correct answer is D: Normal breath sounds. In the scenario described, the nurse hears normal bronchovesicular breath sounds, which are moderate in intensity and resemble blowing as air moves through the larger airways during inspiration and expiration. Crackles (choice A) are typically heard in conditions like heart failure or pneumonia and are not present in this case. Rhonchi (choice B) are low-pitched, continuous sounds often associated with conditions like chronic bronchitis or bronchiectasis. Friction rub (choice C) is a grating sound usually heard in conditions like pleurisy or pericarditis, which is not the case here where normal breath sounds are heard.

3. During a skin assessment, a client expresses concern about skin cancer due to a lesion on the anterior thigh. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?

• A. An uneven shape
• B. A uniformly colored lesion
• C. A lesion that is small and flat
• D. A lesion that is less than 1 cm in diameter

Correct answer: A

Rationale: An uneven shape of a lesion is a common characteristic of malignant skin lesions. Asymmetric or irregularly shaped lesions are concerning for skin cancer and should be reported promptly for further evaluation and management. Choice B, a uniformly colored lesion, is more indicative of a benign lesion as malignant lesions often exhibit variations in color. Choice C, a lesion that is small and flat, does not necessarily indicate malignancy by itself. Choice D, a lesion that is less than 1 cm in diameter, is more suggestive of a benign lesion, as malignant lesions are typically larger in size.

4. A client with chronic kidney disease is experiencing hyperkalemia. Which medication should the LPN/LVN anticipate being prescribed to lower the client's potassium level?

• A. Furosemide (Lasix)
• B. Sodium polystyrene sulfonate (Kayexalate)
• C. Calcium gluconate
• D. Albuterol (Proventil)

Correct answer: B

Rationale: The correct answer is B: Sodium polystyrene sulfonate (Kayexalate). Kayexalate is commonly used to lower potassium levels in clients with hyperkalemia by exchanging sodium ions for potassium ions in the large intestine, leading to the elimination of excess potassium from the body. Choice A, Furosemide (Lasix), is a loop diuretic that helps with fluid retention but does not directly lower potassium levels. Choice C, Calcium gluconate, is used to treat calcium deficiencies and does not impact potassium levels. Choice D, Albuterol (Proventil), is a bronchodilator used to treat respiratory conditions and does not affect potassium levels. Therefore, the LPN/LVN should anticipate the prescription of Kayexalate to address the client's hyperkalemia.

5. A client with a new diagnosis of diabetes mellitus is being taught how to administer insulin. Which of the following instructions should the nurse include?

• A. Administer the insulin in the same body area each time.
• B. Store the insulin according to the manufacturer's instructions.
• C. Rotate injection sites within the same body area.
• D. Inject the insulin at a 45-degree angle.

Correct answer: C

Rationale: The correct instruction the nurse should include is to rotate injection sites within the same body area. This practice helps prevent lipodystrophy, a condition characterized by the thickening or thinning of subcutaneous fat at the injection sites, which can affect insulin absorption. Choice A is incorrect because administering insulin in the same area each time can lead to lipodystrophy. Choice B is incorrect as insulin should be stored according to the manufacturer's instructions, which may include refrigeration. Choice D is incorrect because the angle of insulin injection (usually 90 degrees) is determined by the length of the needle and the amount of subcutaneous fat, not a fixed 45-degree angle.

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