Nursing Elites

1. The LPN/LVN observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?

• A. Observe the appearance of the skin under the ice pack.
• B. Instruct the client regarding the importance of the covering.
• C. Reapply the covering after filling it with fresh ice.
• D. Ask the client how long the ice pack was applied to the skin.

Correct answer: A

Rationale: The correct first action for the nurse to take when a client removes the covering from an ice pack is to observe the appearance of the skin under the ice pack. This assessment is crucial to check for any skin damage or adverse reactions resulting from direct contact with the ice pack. Instructing the client about the importance of the covering (Choice B) can follow the skin assessment. Reapplying the covering (Choice C) before skin assessment may potentially cause harm. Asking the client about the duration of ice application (Choice D) is not the immediate priority; ensuring skin integrity is the primary concern.

2. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

• A. The client's comfort level is increased when the nurse maintains eye contact while typing notes into the record
• B. The interview process is hindered by electronic documentation and may disrupt the flow of conversation
• C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
• D. Completing the electronic record during an interview is optional and not a legal obligation of the examining nurse

Correct answer: C

Rationale: The most accurate statement is that the nurse has a limited ability to observe nonverbal communication while entering the assessment electronically. This is because the nurse's focus is on typing or inputting data, which may lead to missing important nonverbal cues from the client. Choices A and B are incorrect as they do not address the limitation of observing nonverbal cues. Choice A is incorrect because breaking eye contact to type notes may hinder the client's comfort level. Choice B is incorrect because it states that electronic documentation enhances the interview process, which may not always be the case. Choice D is incorrect as completing the electronic record during an interview is typically a standard practice but not a legal obligation.

3. A healthcare professional is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the healthcare professional use as a psychomotor approach to learning?

• A. Practice sessions
• B. Demonstrations
• C. Written instructions
• D. Group discussions

Correct answer: A

Rationale: Practice sessions are an effective psychomotor approach to learning for adolescents with ostomies as they involve hands-on practice of ostomy care skills, which can help reinforce learning through active engagement. Demonstrations (choice B) can be helpful in providing visual guidance but may not offer the same level of active participation and practice as practice sessions. Written instructions (choice C) may be useful for reference but may not be as effective in developing psychomotor skills. Group discussions (choice D) focus more on verbal exchange and may not directly address the need for hands-on skill development required in managing ostomies. Therefore, practice sessions are the most suitable method for enhancing psychomotor learning in this scenario.

4. A client had a mastectomy 6 months ago and expresses a decreased desire for sexual relations, stating “My body is so different now.” Which of the following responses should the nurse make?

• A. “Really, you look just fine to me. There’s no need to feel undesirable.”
• B. “I’m interested in finding out more about how your body feels to you.”
• C. “Consider an afternoon at a spa; a facial will make you feel more attractive.”
• D. “It’s still too soon to expect to feel normal. Give it a little more time.”

Correct answer: B

Rationale: In this situation, the appropriate response is to reflect on the client’s feelings and explore their experience. Choice A may unintentionally dismiss the client's concerns by not addressing their emotional needs. Choice C suggests a spa treatment as a solution without addressing the underlying emotional issues. Choice D implies that the client's feelings will resolve with time, which may not be helpful in addressing the client's current emotional state.

5. A client with a history of peptic ulcer disease reports black, tarry stools. What is the most appropriate action for the LPN/LVN to take?

• A. Reassure the client that this is not a normal finding.
• B. Notify the healthcare provider immediately.
• C. Document the finding in the client’s chart.
• D. Encourage the client to seek medical attention.

Correct answer: B

Rationale: The correct answer is B: Notify the healthcare provider immediately. Black, tarry stools can be indicative of gastrointestinal bleeding, a serious complication that requires urgent medical evaluation and intervention. This finding should not be dismissed or considered normal without further assessment. Option A is incorrect because black, tarry stools are not a normal finding and may signify a significant health issue. Option C is incorrect as immediate action is needed rather than just documenting the finding. Option D is not the best choice as it simply suggests seeking medical attention without emphasizing the urgency of the situation. Prompt notification of the healthcare provider is crucial to ensure timely intervention and management of potential gastrointestinal bleeding.

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