Nursing Elites

1. A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, what should the nurse do?

• A. Lock the wheels on the bed and gurney
• B. Adjust the bed height
• C. Use a slide sheet
• D. Ask for assistance from another nurse

Correct answer: A

Rationale: The correct action for the nurse to take when transferring a postoperative client from the gurney to the bed is to lock the wheels on both the bed and the gurney. Locking the wheels ensures stability and prevents accidents during the transfer. Adjusting the bed height may be necessary for comfort but is not the primary concern during the transfer process. Using a slide sheet may be helpful in repositioning the client once on the bed but is not essential for the initial transfer. Asking for assistance from another nurse is always a good practice, but the immediate action to ensure safety during the transfer is to lock the wheels.

2. During a patient assessment, which principle should be a priority?

• A. Foot care is always important.
• B. Daily bathing is always important.
• C. Hygiene needs are always important.
• D. Critical thinking is always important.

Correct answer: D

Rationale: During a patient assessment, critical thinking is a priority because a patient's condition can change rapidly, necessitating continuous critical thinking and adaptation of nursing interventions. While foot care, daily bathing, and hygiene needs are important components of patient care, they may not always take precedence over critical thinking, which guides the nurse in making timely and appropriate decisions based on the patient's current condition and needs. Therefore, critical thinking stands out as the most crucial principle during patient assessments.

3. A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?

• A. Hypostatic pneumonia
• B. Renal stones
• C. Pressure ulcers
• D. Thrombus formation

Correct answer: B

Rationale: The correct answer is B: Renal stones. Renal calculi are calcium stones that can form in the renal pelvis or pass through the ureters. Immobilized patients, who have hypercalcemia, are at increased risk for developing renal stones. Monitoring for signs and symptoms of renal stones is crucial in this patient population. Choices A, C, and D are incorrect because although they are potential complications in immobilized patients, they are not directly associated with hypercalcemia and do not match the scenario described in the question.

4. When teaching a client and their family how to care for the client’s tracheostomy at home, which of the following should the nurse include?

• A. Use tracheostomy covers when outdoors
• B. Maintain a sterile technique when performing tracheostomy care
• C. Do not remove the outer cannula for routine cleaning
• D. Clean around the stoma with normal saline solution

Correct answer: A

Rationale: The correct answer is to use tracheostomy covers when outdoors. This practice helps protect the stoma from foreign particles and temperature changes, reducing the risk of infection. Maintaining a sterile technique when performing tracheostomy care (choice B) is important to prevent infections but is not specific to outdoor care. Removing the outer cannula for routine cleaning (choice C) is not recommended as it may cause trauma or dislodgment of the tracheostomy tube. Cleaning around the stoma with povidone-iodine (choice D) is not advisable as it can be irritating to the skin and may impair the healing process.

5. A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding 'stronger pain medications.' What initial action is most important for the LPN/LVN to take?

• A. Ask about any past history of drug abuse or addiction.
• B. Measure the pulse volume and capillary refill distal to the infiltration.
• C. Compress the infiltrated tissue to measure the degree of edema.
• D. Evaluate the extent of ecchymosis over the forearm area.

Correct answer: B

Rationale: The most important initial action for the LPN/LVN to take in this situation is to measure the pulse volume and capillary refill distal to the infiltration. This assessment helps evaluate the severity of the infiltration and the circulation in the affected arm. Asking about past history of drug abuse or addiction (Choice A) is not the priority when addressing acute arm pain and infiltration. Compressing the infiltrated tissue (Choice C) may exacerbate the pain and is not recommended as the first step. Evaluating the extent of ecchymosis (Choice D) is not as critical as assessing the circulation in the affected arm, which is better addressed by measuring pulse volume and capillary refill.

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