Nursing Elites

1. The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique. Which technique will the healthcare team use for logrolling?

• A. Involve at least three to four people.
• B. Instruct the patient not to reach for the opposite side rail when turning.
• C. Move the bottom part of the patient’s torso first and then the top part.
• D. Use pillows for support before turning.

Correct answer: A

Rationale: The correct technique for logrolling involves at least three to four people to ensure the safety and proper alignment of the patient's spine. Logrolling requires coordinated effort from multiple individuals to prevent twisting or bending of the spine, hence option A is correct. Option B is incorrect as patients with spinal cord injuries should not be instructed to reach for the opposite side rail due to the risk of causing harm. Option C is incorrect as moving the bottom part of the patient's torso first could lead to spinal misalignment. Option D is incorrect as pillows should be used for support and comfort after the patient has been successfully turned, not before.

2. 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.

3. A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client:

• A. Is unable to swallow foods by mouth
• B. Has a gastrointestinal obstruction
• C. Requires additional caloric intake to support healing
• D. Is at risk for aspiration

Correct answer: A

Rationale: The correct answer is A: 'Is unable to swallow foods by mouth.' Tube feeding is prescribed when a client is unable to safely swallow food by mouth but has a functional gastrointestinal tract. Option B, 'Has a gastrointestinal obstruction,' is incorrect as tube feeding is not typically prescribed for this reason. Option C, 'Requires additional caloric intake to support healing,' is incorrect because tube feeding is specifically for clients who are unable to swallow. Option D, 'Is at risk for aspiration,' is also incorrect as tube feeding would not be the primary intervention for aspiration risk; other strategies to reduce aspiration risk would be implemented instead.

4. During preoperative teaching, a client in a surgeon’s office expresses intent to prepare advance directives before surgery. Which statement by the client indicates understanding of advance directives?

• A. “I’d prefer my brother to make decisions, but I understand it must be my wife.”
• B. “I understand the surgery won’t proceed unless I fill out these forms.”
• C. “I plan to specify my wish to avoid being kept on a breathing machine.”
• D. “I will have my primary doctor review my plan before submitting it at the hospital.”

Correct answer: C

Rationale: The correct answer is C. This statement reflects the client's understanding of advance directives, as it indicates a specific preference regarding life-sustaining treatment. Advance directives enable individuals to outline their healthcare preferences, including decisions about treatments they wish to receive or avoid. Choice A mentions family members but doesn't address specific healthcare wishes; choice B focuses on the surgery rather than personal directives; choice D discusses doctor approval but lacks details about the directive itself.

5. When caring for a client with a tracheostomy, which of the following actions should the nurse take?

• A. Clean the skin around the stoma with normal saline.
• B. Secure the tracheostomy ties with two fingers' width underneath.
• C. Soak the outer cannula in warm tap water.
• D. Use a cotton tip applicator to clean the inside of the inner cannula.

Correct answer: A

Rationale: When caring for a client with a tracheostomy, the nurse should clean the skin around the stoma with normal saline to prevent infection and ensure cleanliness. This action helps in maintaining skin integrity and preventing skin breakdown. Securing the tracheostomy ties with two fingers' width underneath is essential to allow for proper fit, prevent skin irritation, and ensure the ties are not too tight. Soaking the outer cannula in warm tap water is not recommended as it can lead to contamination and is not a standard practice. Using a cotton tip applicator to clean the inside of the inner cannula is discouraged as it can leave fibers behind, increasing the risk of aspiration and respiratory complications.

Similar Questions