Nursing Elites

1. Why is padding on a restraint helpful?

• A. To distribute pressure so that bony prominences do not receive pressure when a client pulls against the restraints.
• B. To help the client feel more secure.
• C. To keep infection and wounds at bay.
• D. To keep restraints in place.

Correct answer: A

Rationale: Padding on a restraint helps distribute pressure to prevent bony prominences from bearing excessive pressure when a client pulls against the restraints. This is crucial to avoid tissue damage caused by ischemia. The correct answer focuses on the physiological benefit of padding in reducing pressure on vulnerable areas to prevent harm. Choice B is incorrect as the primary purpose of padding is not emotional comfort but preventing physical harm. Choice C is incorrect as while padding can indirectly help prevent infection and wounds by reducing pressure, its primary function is pressure distribution. Choice D is incorrect as the main purpose of padding is not to keep the restraints in place but to protect the client's skin and tissues from pressure-related injuries.

2. A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do?

• A. Notify the physician.
• B. Clamp the chest tube.
• C. Replace the system.
• D. Document the finding

Correct answer: D

Rationale: Gentle bubbling is a normal finding for a client with a pleural drainage system to suction, so it simply needs to be documented for monitoring purposes. If the bubbling becomes vigorous, it could indicate a leak, which would then require further investigation by the nurse. Therefore, the correct action at this point is to document the finding. Notifying the physician is not necessary for gentle bubbling as it is expected. Clamping the chest tube or replacing the system is inappropriate and could potentially harm the client as there is no indication for such actions based on the scenario provided.

3. The LPN is caring for a client with an NG tube, and the RN administers evening medications through the NG tube. The client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?

• A. You can lie down in 1 hour.
• B. You can lie down in 30 minutes if your NG residual is below 50 mL.
• C. You can lie down in about 30 minutes.
• D. Yes, feel free to lie down.

Correct answer: A

Rationale: After administering medication through an NG tube, the client should remain upright for 30 minutes to ensure proper absorption of the medications. Therefore, the most appropriate response is to advise the client to lie down in 1 hour. Choice B is incorrect because waiting only 30 minutes may not provide sufficient time for the medications to be fully absorbed, as the recommended time is 30 minutes. Choice C is misleading as it incorrectly suggests that lying down in about 30 minutes is acceptable, which could compromise medication effectiveness. Choice D is incorrect as it does not provide accurate information regarding the appropriate timing for lying down after NG tube medication administration, potentially leading to decreased medication absorption.

4. What should be the primary action for a client who has just vomited 300 cc of bright red blood?

• A. Document the vomiting.
• B. Increase IV fluids.
• C. Get a complete blood count.
• D. Check the blood pressure.

Correct answer: D

Rationale: The correct first action for a client who has just vomited 300 cc of bright red blood is to check the blood pressure. This assessment is crucial to evaluate for hypotension, which could indicate significant blood loss and the need for immediate intervention. Documenting the vomiting is important for the client's medical record but not the initial priority. Increasing IV fluids and getting a complete blood count are necessary steps but should follow the assessment of the client's hemodynamic status.

5. 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.

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