Nursing Elites

1. A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?

• A. Bag bath
• B. Sponge bath
• C. Partial bed bath
• D. Complete bed bath

Correct answer: C

Rationale: The correct answer is a partial bed bath (Choice C). A partial bed bath involves washing body parts that the patient cannot reach on their own, such as the back. It also includes providing assistance with a backrub to promote circulation and skin integrity. In this scenario, where the patient is bedridden and unable to reach all body parts, a partial bed bath is the most appropriate as it focuses on areas the patient cannot clean themselves. Choices A, B, and D are incorrect because a bag bath involves using premoistened disposable cloths for bathing, a sponge bath involves using a basin of water and a sponge for cleansing, and a complete bed bath involves washing the entire body, including areas the patient can reach, which are not necessary in this case.

2. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that are associated with this problem include which of these?

• A. Lymphedema and nerve palsy
• B. Hearing loss and ataxia
• C. Headaches and vomiting
• D. Abdominal mass and weakness

Correct answer: D

Rationale: The correct answer is D: Abdominal mass and weakness. In neuroblastoma, the most common presenting signs are related to the mass effect of the tumor, leading to an abdominal mass and symptoms of weakness. Lymphedema and nerve palsy (Choice A) are not typically associated with neuroblastoma. Hearing loss and ataxia (Choice B) are more indicative of other conditions like neurofibromatosis or brain tumors. Headaches and vomiting (Choice C) are more commonly seen in conditions such as brain tumors or increased intracranial pressure, but they are not specific to neuroblastoma.

3. A client with hypertension is prescribed a low-sodium diet. Which food should the LPN/LVN recommend the client avoid?

• A. Fresh fruits
• B. Grilled chicken
• C. Whole grain bread
• D. Canned soup

Correct answer: D

Rationale: The correct answer is D, canned soup. Canned soup is often high in sodium, which contradicts the low-sodium diet prescribed for hypertension. Fresh fruits (A) are generally low in sodium and are a healthy choice. Grilled chicken (B) is a lean protein option that is suitable for a low-sodium diet. Whole grain bread (C) is also a good choice as it is not typically high in sodium. Therefore, the LPN/LVN should recommend avoiding canned soup to adhere to the low-sodium dietary restrictions.

4. A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.)

• A. “The temperature around the IV site is cooler.”
• B. “The rate of the infusion increases.”
• C. “The skin at the IV site is red.”
• D. “The IV dressing is damp.”

Correct answer: A

Rationale: The correct statement is: 'The temperature around the IV site is cooler.' Cooler temperature around the site is indicative of infiltration, where IV fluid leaks into the surrounding tissue, causing tissue swelling. The other options are incorrect: B) An increase in infusion rate is not a sign of infiltration; instead, it could indicate an issue with the infusion pump or the IV catheter. C) Redness around the IV site is more indicative of infection rather than infiltration. D) A damp IV dressing is more suggestive of a leak in the IV system, not infiltration.

5. A healthcare professional is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care?

• A. HR 105/min
• B. BMI 25 kg/m²
• C. BP 148/92
• D. Glucose 45 mg/dL

Correct answer: D

Rationale: The correct answer is D, 'Glucose 45 mg/dL.' Glucose level of 45 mg/dL indicates hypoglycemia, which is a critical condition requiring immediate attention to prevent complications like seizures, loss of consciousness, and even coma. Hypoglycemia can lead to serious adverse outcomes if not promptly addressed. Choices A, B, and C do not represent immediate life-threatening conditions and can be managed as part of routine care, unlike hypoglycemia which demands urgent intervention.

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