Nursing Elites

1. The LPN is caring for a client taking Lipitor (Atorvastatin). Which of these statements would indicate that the client may need reinforced teaching?

• A. "I take my Lipitor with a glass of milk after my breakfast."?
• B. "I take my Lipitor and wait 30 minutes before taking my other medications."?
• C. "I take my Lipitor 30 minutes after I eat something."?
• D. "I take my Lipitor and my other morning medications with my grapefruit juice at breakfast."?

Correct answer: D

Rationale: The correct answer is, 'I take my Lipitor and my other morning medications with my grapefruit juice at breakfast.' This statement indicates a need for reinforced teaching because grapefruit juice should be avoided when taking Lipitor. Grapefruit juice blocks the enzymes needed to break down the drug, which leads to excessive amounts of the drug in the body. Choices A, B, and C show appropriate timing and administration of Lipitor, whereas choice D poses a potential risk due to the interaction between grapefruit juice and Lipitor.

2. When performing an abdominal assessment, what is the correct order of the tasks?

• A. inspect, percuss, palpate, auscultate
• B. inspect, palpate, percuss, auscultate
• C. inspect, auscultate, percuss, palpate
• D. inspect, palpate, auscultate, percuss

Correct answer: C

Rationale: The correct order of tasks when performing an abdominal assessment is to first inspect the abdomen visually, then auscultate to assess bowel sounds without altering them, followed by percussing to assess the presence of tympany or dullness, and finally palpating to feel for any tenderness, masses, or organ enlargement. Placing palpation or percussion before auscultation, as in choices A, B, and D, can affect the bowel sounds and examination findings, making them incorrect sequences.

3. A nurse assisting with data collection plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal which disorder?

• A. Loss of hearing acuity
• B. A problem with balance
• C. A problem with distant hearing
• D. A problem discriminating high-pitched and low-pitched sounds

Correct answer: B

Rationale: The Romberg test is a balance assessment that evaluates cerebellar function. During the test, the client stands with feet together and eyes closed, aiming to maintain balance for about 20 seconds. This test helps identify issues related to balance and proprioception, not hearing acuity or sound discrimination. Choices C and D are incorrect as the Romberg test focuses on balance, not distant hearing or sound discrimination.

4. When inspecting the client's eyelids for ptosis, the nurse is checking for which abnormality?

• A. Drooping
• B. Pupil dilation
• C. Pupil constriction
• D. Deviation of ocular movements

Correct answer: A

Rationale: When a nurse inspects a client's eyelids for ptosis, they are checking for drooping. Ptosis is a condition characterized by the drooping of the eyelids and can be associated with various disorders such as myasthenia gravis, dysfunction of cranial nerve III, and Bell's palsy. Pupil dilation and constriction are assessed using a flashlight to check pupillary response. Deviation of ocular movements is evaluated by leading the client's eyes through the six cardinal positions of gaze. Therefore, in this scenario, the correct answer is 'Drooping' as it specifically relates to the abnormality associated with ptosis.

5. A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate?

• A. Administering an intravenous (IV) opioid analgesic
• B. Assisting the woman in taking a warm sitz bath
• C. Applying an ice pack to the perineum
• D. Contacting the registered nurse

Correct answer: C

Rationale: Applying an ice pack to the perineum is the most appropriate action in this scenario. Ice causes vasoconstriction, providing relief by numbing the area and preventing edema. It is typically used within the first 12 to 24 hours after birth. Assisting the woman in taking a warm sitz bath is more suitable after 24 hours as warm water can be soothing. Administering an IV opioid analgesic is excessive; an anesthetic spray is more appropriate for surface discomfort. Contacting the registered nurse is unnecessary as applying an ice pack is within the nurse's scope and can effectively address the discomfort without escalation.

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