Nursing Elites

1. The LPN/LVN is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which observation indicates that the client is experiencing oxygen toxicity?

• A. Nasal congestion
• B. Cough
• C. Sore throat
• D. Fatigue

Correct answer: C

Rationale: The correct answer is 'C: Sore throat.' Oxygen toxicity can manifest with symptoms like a sore throat, cough, chest pain, difficulty breathing, and fatigue. However, a sore throat can be an early indicator of oxygen toxicity and should prompt immediate attention. Nasal congestion, cough, and fatigue are not specific indicators of oxygen toxicity but could be related to other factors in a client with COPD receiving oxygen therapy.

2. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate?

• A. I will keep the cast covered the next day to prevent skin burning.
• B. I can apply an ice pack over the area to relieve itching inside the cast.
• C. The cast should be propped on at least 2 pillows when my child is lying down.
• D. I think I remember that standing cannot be done until after 72 hours.

Correct answer: D

Rationale: The correct answer is D because there is no need to wait 72 hours before allowing the child to stand. The synthetic cast does not affect weight-bearing capacity, and standing can be done as tolerated. Choice A is incorrect because keeping the cast covered can lead to damage or accidents. Choice B is acceptable as applying an ice pack can help relieve itching. Choice C is also correct as elevating the cast on pillows can help reduce swelling and promote comfort during rest.

3. When responding to a call light and finding a client on the bathroom floor, what should the nurse do FIRST?

• A. Check the client for injuries
• B. Call for additional help
• C. Move the client to a sitting position
• D. Assist the client back to bed

Correct answer: A

Rationale: Checking the client for injuries is the priority when finding them on the bathroom floor. This action ensures the client's safety as it allows for immediate assessment of any potential harm. Calling for help may be necessary, but assessing for injuries takes precedence to address any immediate threats to the client's well-being. Moving the client to a sitting position or assisting them back to bed should only be done after ensuring there are no serious injuries requiring prompt medical attention. Therefore, the correct first action is to check the client for injuries.

4. While changing the linen on the client's bed, what should the nurse do?

• A. Hold the linen away from their body and clothing.
• B. Fold the linen neatly before placing it in the laundry.
• C. Wear clean gloves while handling the linen.
• D. Place the linen directly on the floor until the new linen is in place.

Correct answer: A

Rationale: When changing the linen on a client's bed, it is essential for the nurse to hold the linen away from their body and clothing. This practice helps prevent contamination and maintain a clean environment. Folding the linen neatly before placing it in the laundry (Choice B) is a good practice but not the immediate action required during linen changing. Wearing clean gloves while handling the linen (Choice C) is important in certain situations but may not be necessary for routine linen changing. Placing the linen directly on the floor until the new linen is in place (Choice D) is incorrect as it can lead to contamination and is not hygienic.

5. A client has restraints on each extremity. Which of the following assessments should the nurse perform first?

• A. Peripheral pulses
• B. Comfort level
• C. Elimination needs
• D. Skin integrity

Correct answer: A

Rationale: When a client is restrained, the nurse should prioritize assessing peripheral pulses first. This assessment is crucial to monitor circulation and ensure the restraints are not impeding blood flow. Comfort level, elimination needs, and skin integrity are also important assessments; however, assessing peripheral pulses takes precedence to prevent complications such as impaired circulation and tissue damage. By assessing peripheral pulses initially, the nurse can promptly identify and address any circulation issues, which are critical in preventing serious complications.

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