Nursing Elites

1. The nurse is preparing to administer a blood transfusion to a client. Which action should the LPN/LVN take to ensure the client's safety?

• A. Check the client's identification and blood type.
• B. Monitor the client's vital signs every hour during the transfusion.
• C. Administer the blood through a peripheral IV line.
• D. Verify the blood product with another nurse before administration.

Correct answer: D

Rationale: To ensure the client's safety during a blood transfusion, it is crucial to verify the blood product with another nurse before administration. This step helps confirm the correct blood type and prevents transfusion reactions. While checking the client's identification and blood type (Choice A) is important, the ultimate responsibility lies with confirming the blood product before administration. Monitoring vital signs (Choice B) is necessary during a transfusion but does not directly address verifying the blood product. Administering blood through a peripheral IV line (Choice C) is a common practice but does not specifically ensure that the correct blood product is being administered, which is essential for the client's safety.

2. A client is prescribed a buccal medication. Which of the following client statements indicates that the client understands how to take this medication?

• A. “I will first dissolve the tablet in water.”
• B. “I will insert the tablet between my cheek and teeth.”
• C. “I will place the tablet under my tongue.”
• D. “I will chew the tablet.”

Correct answer: B

Rationale: The correct way to take buccal medications is to insert the tablet between the cheek and gums where it will dissolve slowly. Option A is incorrect because buccal medications are not meant to be dissolved in water. Option C is incorrect as sublingual medications are placed under the tongue. Option D is incorrect because chewing a buccal tablet is not the correct administration method.

3. A nurse is planning care for a client who has a prescription for knee-length anti-embolic stockings. Which of the following actions should the nurse take?

• A. Remove the client’s stockings at least once during each shift
• B. Roll the top of the client’s stockings down to just below the knee
• C. Seat the client in a chair for 30 minutes prior to applying stockings
• D. Measure the length of the client’s leg from the heel to the gluteal fold

Correct answer: A

Rationale: The correct action for the nurse to take is to remove the client’s stockings at least once during each shift. This is important to inspect the skin and prevent complications such as pressure injuries or impaired circulation. Rolling the top of the stockings down can compromise their effectiveness in preventing blood clots. Seating the client in a chair prior to applying stockings is not directly related to the care of anti-embolic stockings. Measuring the length of the client’s leg from the heel to the gluteal fold is not necessary for the application or care of knee-length anti-embolic stockings.

4. An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The LPN knows that the best position for this client during administration of the feedings is

• A. prone.
• B. Fowler's.
• C. Sims'.
• D. supine.

Correct answer: B

Rationale: Fowler's position is the optimal position for a client receiving tube feedings via a gastrostomy tube because it reduces the risk of aspiration. In Fowler's position, the client is sitting up at a 45- to 60-degree angle, which helps prevent the formula from flowing back into the esophagus and causing aspiration pneumonia. Choice A, prone position (lying face down), would not be suitable for administering tube feedings as it increases the risk of aspiration. Sims' position (lying on the left side with the right knee flexed) and supine position (lying flat on the back) are also not ideal for administering tube feedings as they do not provide the same level of protection against aspiration as Fowler's position does.

5. A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

• A. Dissolve each medication in 5 mL of sterile water.
• B. Draw up each medication separately in the syringe.
• C. Push the syringe plunger gently if feeling resistance.
• D. Flush the tube with 15 mL of sterile water.

Correct answer: D

Rationale: The correct action the nurse should take when administering multiple medications to a client with an enteral feeding tube is to flush the tube with 15-30 mL of sterile water before and between medications, and 30-60 mL after the last medication. This helps prevent clogging and ensures each medication is delivered effectively. Choice A is incorrect as medications should not be dissolved in water for administration through an enteral feeding tube. Choice B is incorrect because each medication should be drawn up and administered separately to prevent any potential interactions. Choice C is incorrect as resistance while pushing the plunger may indicate a problem that needs to be addressed before continuing with the administration.

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