Nursing Elites

1. A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight, and that the client is now lying unconscious on the floor. What is the most important action the LPN/LVN needs to take?

• A. Ask the client if he is okay.
• B. Call security from the room.
• C. Find out if there is anyone else in the room.
• D. Ask security to make sure the room is safe.

Correct answer: D

Rationale: The most critical action for the LPN/LVN to take in this situation is to ask security to ensure the room is safe. This step is crucial to prevent any further harm to the unconscious client or others. While it is important to assess the client's condition, ensuring safety takes precedence. Calling security from the room may expose the LPN/LVN to potential danger without confirming the safety of the environment first. Finding out if anyone else is in the room can wait until safety is established to avoid unnecessary risks.

2. The client is post-operative following abdominal surgery. Which of the following assessment findings would require immediate intervention?

• A. Absent bowel sounds
• B. Saturated abdominal dressing
• C. Pain level of 8/10
• D. Temperature of 100.4°F

Correct answer: B

Rationale: A saturated abdominal dressing is a critical finding that may indicate active bleeding or wound complications. Immediate intervention is necessary to prevent further complications, such as hypovolemic shock or infection. Absent bowel sounds, though abnormal, are a common post-operative finding and do not require immediate intervention. Pain level of 8/10 can be managed effectively with appropriate pain control measures and does not indicate an urgent issue. A temperature of 100.4°F is slightly elevated but may be a normal post-operative response to surgery and does not typically require immediate intervention unless accompanied by other concerning signs or symptoms.

3. A healthcare professional is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

• A. Ventrogluteal
• B. Dorsogluteal
• C. Deltoid
• D. Vastus lateralis

Correct answer: A

Rationale: The ventrogluteal site is considered the safest for intramuscular injections in young adult clients due to its location away from major nerves and blood vessels. The ventrogluteal site is preferred over the dorsogluteal site, as the latter is associated with a higher risk of injury to the sciatic nerve. The deltoid site is commonly used for vaccines but may not be suitable for all intramuscular injections due to smaller muscle mass. The vastus lateralis site is often used in infants and young children, but in young adults, the ventrogluteal site is preferred for safety and efficacy.

4. The LPN is caring for a client who has been placed in restraints. What is the most important action for the nurse to take?

• A. Ensure that the client’s circulation is checked every hour.
• B. Document the reason for the restraints every 4 hours.
• C. Provide range-of-motion exercises every 2 hours.
• D. Release the restraints every 2 hours for repositioning.

Correct answer: D

Rationale: The most crucial action for the nurse to take when caring for a client in restraints is to release the restraints every 2 hours for repositioning. This practice helps prevent complications such as pressure ulcers and impaired circulation by ensuring adequate blood flow and preventing skin breakdown. Checking the client's circulation every hour (Choice A) is important, but releasing the restraints for repositioning takes precedence to prevent serious complications. While documenting the reason for restraints (Choice B) is essential for legal and documentation purposes, it is not as critical as providing necessary care to the client's physical well-being. Providing range-of-motion exercises (Choice C) is beneficial for maintaining mobility but may not address the immediate risks associated with prolonged restraint use.

5. What is the most important aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery?

• A. Demonstration of appropriate hand hygiene
• B. Explanation of wound care technique
• C. Review of signs and symptoms of infection
• D. Instructions for when to contact the healthcare provider

Correct answer: A

Rationale: The most critical aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery is the demonstration of appropriate hand hygiene. Proper hand hygiene is essential to prevent the introduction of infection during dressing changes. While wound care technique, signs and symptoms of infection, and instructions for contacting the healthcare provider are all important components of the discharge plan, ensuring the client understands and practices proper hand hygiene is paramount to minimize the risk of infection. This choice takes precedence as it directly addresses infection prevention during the dressing changes, which is crucial for successful post-operative recovery.

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