Nursing Elites

1. The LPN needs to determine the client's respiratory rate. What is the best technique to do this?

• A. Tell the client you need to count their respiratory rate.
• B. Subtly watch the client from across the room when they are doing an activity.
• C. Ask the client to sit still for 30 seconds.
• D. Count respirations while pretending to check the client's pulse.

Correct answer: D

Rationale: The best technique to determine a client's respiratory rate is to count respirations while pretending to check the client's pulse. You should not inform the client that you are counting their respirations, as this might lead to a change in their breathing pattern. Pretending to check the pulse allows you to be close to the client without revealing that you are assessing their respiratory rate. Asking the client to sit still may not be as effective, as it may cause them to concentrate on their breathing. Watching from across the room may not provide an accurate assessment of respirations, as they might be difficult to observe.

2. A clinic nurse about to meet a new client plans to gather subjective data regarding the client's health history. Which action does the nurse take to help ensure the success of the interview?

• A. Ensuring that the room is private
• B. Having the client sit across from the nurse without a desk or table between them
• C. Maintaining a distance of 4 to 5 feet between the nurse and client
• D. Adjusting the room lighting to ensure it is comfortable and conducive for the client

Correct answer: A

Rationale: The physical environment of an interview room should provide optimal conditions to encourage a smooth interview and make the client feel comfortable. The nurse ensures that privacy is maintained to avoid interruptions during the interview. This helps create a safe space for the client to share sensitive information. Having the client sit across from the nurse without a desk or table between them is also important to promote open communication and build rapport. Maintaining a distance of 4 to 5 feet from the client respects their personal space and helps prevent the client from feeling overwhelmed. While adjusting the room lighting is beneficial for creating a comfortable atmosphere, ensuring privacy is crucial for establishing trust and confidentiality. Therefore, ensuring that the room is private is crucial for the success of the interview, making choice A the correct answer. Choices B, C, and D are incorrect as they do not directly address the importance of privacy in creating a conducive environment for the interview.

3. The LPN is taking care of a 176-pound client who has recently been diagnosed with diabetes. The primary healthcare provider has written an order for Lantus� (insulin glargine injection) 100 units/mL, using weight-based dosing of 0.2 units/kg per day. The LPN should prepare ____ units for administration.

• A. 12
• B. 35
• C. 16
• D. 9

Correct answer: B

Rationale: To calculate the correct dosage, first convert the client's weight from pounds to kilograms. As 1 kg = 2.2 pounds, 176 pounds � 2.2 = 80 kg. The client should receive 0.2 units for every kilogram, which equals 16 units. Therefore, the total amount to prepare is 16 units x 100 units/mL = 1600 units. Considering the medication concentration of 100 units/mL, 1600 units � 100 units/mL = 16 mL. However, since the question asks for the number of units, the final answer is 16 units x 2 injections = 32 units. Therefore, the LPN should prepare 32 units for administration.

4. When preparing to assist the healthcare provider in examining a client's skin with the use of a Wood light, what action should the nurse perform?

• A. Darken the room
• B. Obtain informed consent from the client
• C. Obtain a scalpel and a slide for diagnostic evaluation
• D. Obtain medication to anesthetize the skin area before proceeding with the examination

Correct answer: A

Rationale: When using a Wood light during a skin examination, the room should be darkened to enhance the visibility of fluorescence. The Wood light emits long-wavelength ultraviolet light, highlighting certain skin conditions. Darkening the room aids in better visualization. Obtaining informed consent is a crucial aspect of healthcare but not directly related to using a Wood light. Obtaining a scalpel and a slide is unnecessary for a noninvasive Wood light examination. Anesthetizing the skin area is not required as the procedure is painless and noninvasive.

5. During a report from an ER nurse about a client, the nurse identifies a statement that requires additional follow-up. Which of the following statements needs further clarification?

• A. "The client said they have been taking aspirin, but I'm not sure for how long or how much."?
• B. "The client frequently takes antacids, but they have not taken any in the last three days."?
• C. "The client stopped taking ibuprofen after developing gastric ulcers."?
• D. "The client takes Antabuse and has stopped using mouthwash."?

Correct answer: A

Rationale: The correct answer requires further follow-up as the nurse needs to know the duration and dosage of aspirin since it can impact the patient's bleeding risk. Choice B does not require immediate follow-up as not taking antacids for three days is not critical. Choice C indicates a necessary decision made by the client to stop ibuprofen after developing gastric ulcers, hence no immediate follow-up is needed. Choice D provides important information, but the priority is to address the lack of specificity regarding the client's aspirin use, which is crucial for assessing bleeding risk and potential interactions.

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