Nursing Elites

1. The LPN/LVN is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?

• A. A college-age track runner with a sprained ankle.
• B. A lactating woman nursing her 3-day-old infant.
• C. A school-aged child with Type 2 diabetes.
• D. An elderly man being treated for a peptic ulcer.

Correct answer: B

Rationale: The correct answer is B, a lactating woman nursing her 3-day-old infant. During lactation, women have increased nutritional needs, including protein, to support milk production for their infants. Protein is essential for proper growth and development. While choice A, a college-age track runner with a sprained ankle, may require protein for tissue repair, the lactating woman's need is greater due to the demands of breastfeeding. Choice C, a school-aged child with Type 2 diabetes, may have specific dietary considerations related to diabetes management but does not necessarily require additional protein intake compared to a lactating woman. Choice D, an elderly man being treated for a peptic ulcer, may need protein for wound healing, but the nutritional need for a lactating woman is higher to support her infant's growth.

2. While assisting a client with a meal, the client suddenly grabs at their neck with both hands and appears frightened. The appropriate nursing action is to:

• A. Ask the client if they are choking
• B. Perform abdominal thrusts
• C. Call for emergency help
• D. Check the client’s airway

Correct answer: A

Rationale: The correct action when a client suddenly grabs at their neck and appears frightened is to ask if they are choking. This allows the nurse to gather more information from the client directly. Performing abdominal thrusts (choice B) should only be done if the client is unable to speak, cough, or breathe. Calling for emergency help (choice C) should be done after assessing the situation and confirming choking. Checking the client's airway (choice D) is important but should come after confirming that the client is choking.

3. A client with heart failure and a new prescription for hydrochlorothiazide is receiving discharge teaching about safety considerations from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “I will take a hot bath before going to bed.”
• B. “I will take my new medication in the evening.”
• C. “I will leave a light on in my bathroom at night.”
• D. “I will weigh myself once weekly.”

Correct answer: C

Rationale: The correct answer is C. Leaving a light on in the bathroom at night is important for an older adult with heart failure who is taking hydrochlorothiazide, a diuretic that can cause nocturia. This safety measure helps prevent falls during nighttime bathroom visits. Option A is incorrect because taking a hot bath before bed can increase the risk of falls due to potential dizziness. Option B does not directly relate to safety considerations but rather the timing of medication administration. Option D, weighing oneself once weekly, is important for monitoring fluid retention but does not address safety concerns related to nocturia and falls.

4. While observing a student nurse administering a narcotic analgesic IM injection without aspirating, what should the nurse do?

• A. Ask the student, 'What did you forget to do?'
• B. Stop and explain why aspiration is needed.
• C. Quietly state, 'You forgot to aspirate.'
• D. Walk up and whisper in the student's ear, 'Stop. Aspirate. Then inject.'

Correct answer: D

Rationale: When the nurse observes a student nurse making a mistake during a procedure, such as not aspirating before administering a medication, the nurse should provide immediate, discreet feedback to correct the error. Walking up and whispering in the student's ear to stop, aspirate, and then inject is appropriate as it corrects the mistake while maintaining the student's dignity and confidence. Option A is not as effective as it indirectly addresses the issue. Option B is not the best approach as the student needs immediate correction. Option C is not ideal as loudly stating the mistake may embarrass the student and is not necessary for a discreet correction.

5. During an admission assessment of an older adult client, a nurse should identify which of the following findings as a potential indication of abuse?

• A. Bruises on the arms in various stages of healing
• B. Recent weight gain
• C. Complaints of joint pain
• D. Frequent visits to different providers

Correct answer: A

Rationale: Bruises on the arms in various stages of healing should be identified as a potential indication of abuse in an older adult. These bruises may suggest physical harm or neglect, which are concerning signs of abuse. Recent weight gain (Choice B) is not typically associated with abuse and can have various causes, such as dietary changes or health conditions. Complaints of joint pain (Choice C) are more likely related to musculoskeletal issues rather than abuse. Frequent visits to different providers (Choice D) could indicate seeking multiple opinions or healthcare needs and do not necessarily point to abuse.

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