Nursing Elites

1. What is the most important action for the LPN/LVN to take to prevent infection in a client with an indwelling urinary catheter?

• A. Ensure the catheter tubing is free of kinks.
• B. Change the catheter every 72 hours.
• C. Clean the perineal area with an antiseptic solution daily.
• D. Irrigate the catheter with normal saline every shift.

Correct answer: A

Rationale: The most crucial action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. This step helps prevent obstruction in the tubing, maintaining proper urine flow and reducing the risk of infection. Changing the catheter every 72 hours is not recommended unless clinically indicated, as routine changes can increase the risk of introducing pathogens. Cleaning the perineal area with an antiseptic solution is essential for general hygiene but does not directly prevent catheter-related infections. Irrigating the catheter with normal saline every shift is not a standard practice and can introduce microorganisms into the urinary tract, increasing the risk of infection.

2. During a skin assessment, a client expresses concern about skin cancer due to a lesion on the anterior thigh. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?

• A. An uneven shape
• B. A uniformly colored lesion
• C. A lesion that is small and flat
• D. A lesion that is less than 1 cm in diameter

Correct answer: A

Rationale: An uneven shape of a lesion is a common characteristic of malignant skin lesions. Asymmetric or irregularly shaped lesions are concerning for skin cancer and should be reported promptly for further evaluation and management. Choice B, a uniformly colored lesion, is more indicative of a benign lesion as malignant lesions often exhibit variations in color. Choice C, a lesion that is small and flat, does not necessarily indicate malignancy by itself. Choice D, a lesion that is less than 1 cm in diameter, is more suggestive of a benign lesion, as malignant lesions are typically larger in size.

3. A client is receiving chemotherapy for breast cancer. Which laboratory value would be most important for the nurse to monitor?

• A. White blood cell count
• B. Hemoglobin level
• C. Serum creatinine
• D. Blood glucose level

Correct answer: A

Rationale: The correct answer is to monitor the white blood cell count. Chemotherapy can lead to neutropenia, which is a decrease in white blood cells, particularly neutrophils. Neutropenia increases the risk of infections, making it crucial to monitor the white blood cell count during chemotherapy. Monitoring hemoglobin level is important but not as critical as white blood cell count in this scenario. Serum creatinine and blood glucose levels are not directly impacted by chemotherapy for breast cancer, making them less relevant to monitor in this situation.

4. During a patient assessment, which principle should be a priority?

• A. Foot care is always important.
• B. Daily bathing is always important.
• C. Hygiene needs are always important.
• D. Critical thinking is always important.

Correct answer: D

Rationale: During a patient assessment, critical thinking is a priority because a patient's condition can change rapidly, necessitating continuous critical thinking and adaptation of nursing interventions. While foot care, daily bathing, and hygiene needs are important components of patient care, they may not always take precedence over critical thinking, which guides the nurse in making timely and appropriate decisions based on the patient's current condition and needs. Therefore, critical thinking stands out as the most crucial principle during patient assessments.

5. A client asks a nurse about the purpose of advance directives.

• A. Indicate a form of treatment a client is willing to accept.
• B. Specify the client's preferred hospital for treatment.
• C. Determine the client's daily medication schedule.
• D. Outline the client's financial status and insurance coverage.

Correct answer: A

Rationale: The correct answer is A: Advance directives serve to indicate the forms of medical treatment a client wishes to receive or decline in the event they are unable to communicate their preferences. This legal document allows individuals to make decisions about their future healthcare. Choice B is incorrect as advance directives do not specify the client's preferred hospital for treatment. Choice C is incorrect as advance directives do not determine the client's daily medication schedule; this is typically addressed in a medication administration record. Choice D is incorrect as advance directives do not outline the client's financial status and insurance coverage, but rather focus on healthcare treatment preferences.

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