Nursing Elites

1. The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next?

• A. Insert an oral airway.
• B. Place the patient in a flat, supine position.
• C. Use undiluted hydrogen peroxide as a cleaner.
• D. Quickly proceed without talking to the patient.

Correct answer: A

Rationale: When a debilitated patient resists oral hygiene, the nurse should prioritize safety. Inserting an oral airway helps keep the mouth open, ensuring adequate access for oral care procedures while preventing any accidental biting or closure of the airway. Placing the patient in a flat, supine position may not address the resistance issue and can lead to aspiration risk. Using undiluted hydrogen peroxide is not recommended due to its potential harmful effects on oral tissues. Proceeding quickly without communication can escalate the situation and compromise patient-centered care.

2. A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?

• A. Hypostatic pneumonia
• B. Renal stones
• C. Pressure ulcers
• D. Thrombus formation

Correct answer: B

Rationale: The correct answer is B: Renal stones. Renal calculi are calcium stones that can form in the renal pelvis or pass through the ureters. Immobilized patients, who have hypercalcemia, are at increased risk for developing renal stones. Monitoring for signs and symptoms of renal stones is crucial in this patient population. Choices A, C, and D are incorrect because although they are potential complications in immobilized patients, they are not directly associated with hypercalcemia and do not match the scenario described in the question.

3. A client with chronic kidney disease is experiencing hyperkalemia. Which medication should the LPN/LVN anticipate being prescribed to lower the client's potassium level?

• A. Furosemide (Lasix)
• B. Sodium polystyrene sulfonate (Kayexalate)
• C. Calcium gluconate
• D. Albuterol (Proventil)

Correct answer: B

Rationale: The correct answer is B: Sodium polystyrene sulfonate (Kayexalate). Kayexalate is commonly used to lower potassium levels in clients with hyperkalemia by exchanging sodium ions for potassium ions in the large intestine, leading to the elimination of excess potassium from the body. Choice A, Furosemide (Lasix), is a loop diuretic that helps with fluid retention but does not directly lower potassium levels. Choice C, Calcium gluconate, is used to treat calcium deficiencies and does not impact potassium levels. Choice D, Albuterol (Proventil), is a bronchodilator used to treat respiratory conditions and does not affect potassium levels. Therefore, the LPN/LVN should anticipate the prescription of Kayexalate to address the client's hyperkalemia.

4. After preparing and lubricating the enema set, what is the correct sequence of steps a nurse should follow when administering a large volume enema to a client?

• A. Administer the enema solution.
• B. Remove the enema tube from the client's rectum.
• C. Wrap the end of the enema tube with a disposable tissue.
• D. Insert the enema tube into the client's rectum.

Correct answer: B

Rationale: The correct sequence for administering a large volume enema is as follows: 1. Insert the enema tube into the rectum, 2. Administer the enema solution, 3. Clamp the tube, 4. Remove the tube, 5. Wrap the end with tissue. Therefore, the nurse should remove the enema tube from the client's rectum after administering the enema solution. Choices A, C, and D are incorrect because the enema tube should be removed from the rectum after the administration of the solution, not before or during the process.

5. A client with pneumonia is receiving antibiotic therapy. Which finding indicates that the treatment is effective?

• A. Decreased white blood cell count
• B. Decreased respiratory rate
• C. Increased breath sounds
• D. Increased heart rate

Correct answer: C

Rationale: The correct answer is C: Increased breath sounds. When a client with pneumonia is receiving antibiotic therapy, increased breath sounds indicate that the lungs are clearing and the pneumonia is resolving. This improvement in breath sounds suggests that the antibiotics are effectively treating the infection. Choices A, B, and D are incorrect because a decreased white blood cell count, decreased respiratory rate, and increased heart rate are not specific indicators of the effectiveness of antibiotic therapy in treating pneumonia. While these parameters may change in response to treatment, they do not directly reflect the resolution of the pneumonia infection.

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