Nursing Elites

1. Which of the following clients would be most appropriate for an LPN to assign to a nursing assistant?

• A. an 18-year-old client with a femur fracture who is just returning to the floor from the recovery unit
• B. an 84-year-old client 2 days post-op after knee replacement surgery who needs help ambulating
• C. a 35-year-old client who is suffering from an acute asthma attack
• D. a 20-year-old client with Cystic Fibrosis who needs an early morning sputum sample collection

Correct answer: D

Rationale: Collecting sputum samples on stable clients is within the scope of practice for an LPN. This task does not require immediate intervention or assessment by an RN or medical provider. An RN should perform the initial assessment on any client immediately post-op as it requires a higher level of assessment and monitoring. A client suffering from an acute asthma attack should be attended to by an RN or medical provider due to the potential severity and need for prompt intervention. Assigning a medically stable client who needs help ambulating to a nursing assistant is appropriate as it falls within their scope of practice and allows the LPN to focus on tasks that require their expertise.

2. Which hormone in the urine is specifically indicative of pregnancy?

• A. estrogen
• B. progesterone
• C. testosterone
• D. human chorionic gonadotropin

Correct answer: D

Rationale: Human chorionic gonadotropin is the hormone specifically indicative of pregnancy as it is produced by the placenta after implantation. It can be detected in urine and blood samples to confirm pregnancy. Estrogen and progesterone play crucial roles in the menstrual cycle and pregnancy but are not specific indicators of pregnancy on their own. Testosterone is a hormone primarily associated with male reproductive functions and is not directly related to pregnancy, making it an incorrect choice in this context.

3. While working the 11 p.m. to 7 a.m. shift at the long-term care unit, the nurse gathers the nursing staff to listen to the 3 to 11 p.m. intershift report. The nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait, suspecting alcohol intoxication. What is the most appropriate action for the nurse to take?

• A. Contact the nursing supervisor.
• B. Tell the staff member that she is not allowed to administer medications.
• C. Ask the staff member how much alcohol she has consumed.
• D. Ask the staff member to rest in the nurses' lounge until the effects of the alcohol wear off.

Correct answer: A

Rationale: When a staff member reports to work showing signs of alcohol intoxication, the nurse should objectively note the symptoms and ask a second person to confirm these observations. It is crucial to contact the nursing supervisor immediately. An odor of alcohol, slurred speech, unsteady gait, and errors in judgment are indicators of intoxication, posing a risk to client safety. The staff member should be removed from the client care area. Detailed documentation of the incident is essential, including observations, actions taken, future plans, and the staff member's signature and date on the recorded incident memo. If the staff member refuses to sign, this should be noted by the nurse and a witness. Asking the staff member to rest in the nurses' lounge or restricting medication administration does not ensure client safety, as the staff member could still jeopardize it. Inquiring about the amount of alcohol consumed is confrontational and not relevant to the immediate need of ensuring safety.

4. To what does legal protection of confidentiality extend?

• A. Written documentation only.
• B. Electronic dissemination of information not identifiable to a specific client.
• C. Only within the court system.
• D. Both written and verbal information.

Correct answer: D

Rationale: Legal protection of confidentiality extends to both written and verbal information that is identifiable as individual private health information. Confidentiality in healthcare settings is vital to protect patients' privacy and trust. Choice A is incorrect because legal protection covers verbal information as well, not just written documentation. Choice B is incorrect as it mentions information not identifiable to a specific client, which wouldn't fall under legal protection of confidentiality. Choice C is incorrect as confidentiality extends beyond just the court system, impacting various healthcare settings and interactions. Therefore, the correct answer is D.

5. Which of these would be an appropriate meal for a client with Celiac disease?

• A. egg noodles with cream sauce and broccoli, oat cookie, almond milk
• B. turkey sandwich with rye bread, carrots
• C. chicken and rice, apple, and tapioca pudding
• D. granola and dried apricots with cow's milk

Correct answer: C

Rationale: For individuals with Celiac disease, it's crucial to avoid gluten-containing foods. Choice C, which includes chicken, rice, apple, and tapioca pudding, is the most suitable option as all these foods are naturally gluten-free. Rice, fruits, vegetables, meat, dairy, and tapioca are all safe gluten-free options. Oats can be gluten-free if specially labeled, but many are processed on shared equipment with wheat. Granola often contains oats that may have been exposed to gluten. Dried and prepackaged fruits may contain gluten additives. Rye is a wheat derivative, and cream sauces usually contain flour as a base, making choices A and B inappropriate for individuals with Celiac disease.

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