Nursing Elites

1. The LPN notices a client with poor gait and balance. She is currently being treated for hypertension, but the nurse is concerned. What should the nurse do?

• A. Add this issue to the nursing care plan and include daily gait/balance training as an intervention.
• B. Do nothing as this is unrelated to the client's hospitalization.
• C. Speak with the attending physician about the concerns and request a referral for the client to go to physical therapy.
• D. Speak with the attending physician about the concerns and request a referral to physical therapy.

Correct answer: D

Rationale: Nurses should address any concerns regarding a client's health, even if they are not directly related to the reason for hospitalization. In this case, the nurse noticing the client's poor gait and balance should communicate these concerns to the attending physician. The correct course of action is to request a referral to physical therapy, as this specialized intervention can help address the client's issues effectively. Adding gait/balance training to the care plan without professional assessment and intervention may not be appropriate. Doing nothing is not in line with providing comprehensive care, and referring the client to the hospital gym is not as effective as a referral to physical therapy for addressing gait and balance issues.

2. All of the following tasks could be delegated to a nursing assistant or unlicensed assistive personnel (UAP) except:

• A. monitoring intravenous infusion
• B. assisting a client to the bathroom
• C. offering fluid intake every 1-2 hours
• D. monitoring/recording the amount of fluid taken

Correct answer: A

Rationale: Monitoring an intravenous infusion involves assessing for complications, adjusting the flow rate, and monitoring the client's response, which requires the knowledge and skills of a licensed nurse (RN or LPN). Tasks that can be delegated to nursing assistants or unlicensed assistive personnel include assisting a client to the bathroom, offering fluids, and recording fluid intake. These activities are within the scope of practice for UAPs as they do not involve the specialized knowledge and training needed for intravenous infusion monitoring.

3. A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy's mother indicates a need for further teaching by the nurse?

• A. "I should make sure he gets plenty of rest."?
• B. "I should get him a medical alert bracelet."?
• C. "I should lay him on his back during a seizure."?
• D. "I should loosen his clothing during a seizure."?

Correct answer: C

Rationale: The correct answer is "I should lay him on his back during a seizure."? This statement indicates a need for further teaching because a client having a seizure should be turned to the side to prevent aspiration of secretions. Choices A, B, and D are correct. Getting plenty of rest helps in managing seizures, having a medical alert bracelet informs others about the condition in case of emergency, and loosening clothing during a seizure ensures better air circulation and prevents injury. These actions demonstrate adequate understanding of the teaching provided.

4. Which of the following statements indicates that the provider understands how to promote rest and sleep for the client?

• A. If you would prefer not to be disturbed, we can postpone all vital signs and assessments until tomorrow morning.
• B. With your physical therapy appointments, you cannot nap more during the day even if your sleep is often interrupted at nighttime.
• C. I can try to incorporate any sleep rituals or an ideal bedtime into your routine.
• D. We cannot group together medications, assessments, and other interventions so you may have multiple interruptions at night.

Correct answer: C

Rationale: The correct answer is, 'I can try to incorporate any sleep rituals or an ideal bedtime into your routine.' To promote rest and sleep, the provider should consider incorporating the client's preferred sleep rituals or bedtime routine. This statement shows an understanding of the importance of individualizing care to promote restful sleep. Choices A, B, and D do not directly address promoting rest and sleep. Choice A focuses on postponing assessments, Choice B addresses napping during the day, and Choice D mentions multiple interruptions at night, none of which directly support promoting rest and sleep for the client.

5. When the healthcare provider is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client?

• A. corner of the mouth to tragus of the ear
• B. corner of the eye to top of the ear
• C. tip of the chin to the sternum
• D. tip of the nose to the earlobe

Correct answer: D

Rationale: A nasopharyngeal airway is measured from the tip of the nose to the earlobe. This measurement ensures that the airway is of the correct length to reach the nasopharynx without being too long or too short. Choices A, B, and C are incorrect as they do not provide the appropriate measurement for selecting the correct size of a nasopharyngeal airway. The distance from the corner of the mouth to the tragus of the ear (Choice A) is used to measure for an oropharyngeal airway, not a nasopharyngeal airway. Similarly, the other choices (B and C) do not correlate with the correct measurement of a nasopharyngeal airway.

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