Nursing Elites

1. For a client requiring total oral care, it is important for the nurse to:

• A. assemble all equipment, assist the client to a semi-Fowler's position, and place a towel on his chest.
• B. place the client in Fowler's position, prepare the equipment, and instruct the client what to do.
• C. assemble all equipment, place the client in a side-lying position, and place a towel under his chin.
• D. use gloves and clean the client's mouth, including the tongue.

Correct answer: C

Rationale: To provide total oral care to a client, the nurse should first assemble all necessary equipment. Placing the client in a side-lying position helps fluids to easily flow out or pool in the side of the mouth for suctioning, thus preventing aspiration. Additionally, placing a towel under the client's chin and a curved basin against the chin helps to maintain cleanliness during the procedure. Choice A is incorrect because the client should be placed in a side-lying position, not a semi-Fowler's position which is used for respiratory issues. Choice B is incorrect as it does not emphasize the importance of proper positioning for effective oral care. Choice D is incorrect as it oversimplifies the procedure by focusing only on cleaning the mouth without considering the importance of positioning and preparation.

2. When ambulating a client with right-sided weakness, a nursing assistant should be positioned on which side of the client?

• A. Stands behind the client
• B. Positions the free hand on the client's shoulder
• C. Stands on the right side of the client
• D. Grasps the security belt in the midspine area of the small of the client's back

Correct answer: C

Rationale: When ambulating a client with right-sided weakness, the nursing assistant should stand on the affected side, which in this case is the client's right side. This position allows the assistant to provide proper support and assistance. Standing behind the client (Choice A) is incorrect as the assistant should be on the affected side. Positioning the free hand on the client's shoulder (Choice B) is a correct action as it helps in pulling the client toward them in case of a forward fall. Grasping the security belt in the midspine area of the small of the client's back (Choice D) is also correct to provide support and stability during ambulation.

3. When removing a client's gown with an intravenous line, what should the nurse do?

• A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown
• B. cut the gown with scissors
• C. thread the bag and tubing through the gown sleeve, keeping the line intact
• D. temporarily disconnect the tubing from the intravenous container and thread it through the gown

Correct answer: C

Rationale: The correct action when removing a client's gown with an intravenous line is to thread the bag and tubing through the gown sleeve while keeping the line intact. This method ensures that the system remains sterile and reduces the risk of infection. Temporarily disconnecting the tubing at a point close to the client or from the container introduces the potential for contamination. Cutting the gown with scissors should only be done in emergencies as it is not a standard practice and can compromise the integrity of the intravenous line. Therefore, the most appropriate and safe method is to thread the bag and tubing through the gown sleeve.

4. While observing a client using crutches for a leg injury, which action would indicate a need for more education by the LPN?

• A. The client places the top padding 1-2 inches below the axilla with a firm grip on the handles.
• B. The client rests the axilla on the top padding and loosely grips the handles with hands.
• C. The client has a slight bend in the elbow when using the handles.
• D. When going down the stairs, the client leads with the injured leg.

Correct answer: B

Rationale: The correct answer is B. Resting the axilla on the top padding can cause nerve damage; instead, the client should place the top padding 1-2 inches below the axilla with a firm grip on the handles for proper support and stability while using crutches. Having a slight bend in the elbow when using the handles (choice C) is a correct technique to ensure proper weight distribution. Leading with the uninjured leg when going down the stairs (choice D) is the correct way to maintain balance and prevent further injury to the injured leg. Therefore, choice B indicates a need for more education to prevent potential nerve damage and ensure safe crutch use.

5. When a client's postoperative pain seems to be getting worse due to grief over the recent death of their spouse, what should the nurse consider?

• A. calling the physician for an increased dosage of pain medication
• B. calling the physician for a sedative
• C. referring the client for a psychiatric consult
• D. developing interventions for grief and loss

Correct answer: D

Rationale: The correct answer is developing interventions for grief and loss. In this scenario, the client's pain is not solely sensory but also affective due to grieving over the death of their spouse. It is essential to address the emotional component of pain by providing support and interventions for grief and loss. Referring the client for a psychiatric consult may not be necessary as grieving is a normal response to such a significant loss. Calling the physician for an increased dosage of pain medication or a sedative solely focuses on the sensory aspect of pain and does not address the underlying emotional distress.

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