Nursing Elites

1. The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?

• A. Place the chair at a right angle to the bed on the client's left side before moving.
• B. Assist the client to a standing position, then place the right hand on the armrest.
• C. Have the client place the left foot next to the chair and pivot to the left before sitting.
• D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

Correct answer: D

Rationale: The correct method for transferring an elderly client with left-sided weakness from the bed to the chair involves moving the chair parallel to the right side of the bed and standing the client on the right foot. This technique provides a stable and safe transfer by utilizing the stronger side of the client to support the transfer. Choices A, B, and C are incorrect because placing the chair at a right angle to the bed on the client's left side, assisting the client to a standing position and placing the right hand on the armrest, and having the client pivot to the left before sitting do not address the client's left-sided weakness and may increase the risk of falls or injuries.

2. When caring for a client prescribed a blood transfusion that parents refuse due to religious beliefs, what should the nurse do?

• A. Examine personal values about the issue.
• B. Proceed with the transfusion if medically necessary.
• C. Refer the issue to the ethics committee.
• D. Administer the blood transfusion without informing the parents.

Correct answer: A

Rationale: When faced with a situation where parents refuse a prescribed treatment due to religious beliefs, the nurse should first examine personal values, understand the client's or family’s beliefs, and respect their rights. Proceeding with the transfusion against the parents' wishes without exploring alternatives or understanding their perspective would violate the principle of respect for autonomy and could damage the therapeutic relationship. Referring the issue to the ethics committee should be considered if a resolution cannot be reached through open communication and negotiation with the family.

3. A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which laboratory value should the LPN/LVN monitor closely while the client is taking this medication?

• A. Blood glucose level
• B. Prothrombin time (PT) and INR
• C. Serum potassium level
• D. Serum creatinine level

Correct answer: B

Rationale: The LPN/LVN should closely monitor Prothrombin time (PT) and INR (Choice B) levels in a client receiving warfarin. These values are crucial to ensure the medication's effectiveness and prevent complications like bleeding. Monitoring blood glucose level (Choice A) is not directly relevant to warfarin therapy. While serum potassium level (Choice C) and serum creatinine level (Choice D) are important for other conditions or medications, they are not specifically required to be monitored when a client is on warfarin.

4. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

• A. Carefully remove the gloves and follow with hand hygiene
• B. Continue with the procedure and clean hands later
• C. Remove the gloves, wash hands, and start over
• D. Use hand sanitizer and continue the procedure

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to carefully remove the gloves and follow with hand hygiene. This is important to prevent potential contamination and maintain infection control practices. Option B is incorrect because cleaning hands later may lead to the spread of potential contaminants. Option C is unnecessary as starting over is not required if proper hand hygiene is performed. Option D is not sufficient in ensuring proper hygiene after a blood spill, as hand sanitizer may not effectively remove all contaminants.

5. A client scheduled for arthroplasty expresses concern about the risk of acquiring an infection from a blood transfusion. Which of the following statements should the nurse make to the client?

• A. Donate autologous blood before the surgery
• B. Request a specific blood type from the donor
• C. Use blood from a family member
• D. Accept allogeneic blood without concerns

Correct answer: A

Rationale: The correct statement for the nurse to make to the client is to 'Donate autologous blood before the surgery.' Autologous blood donation involves collecting and storing the client's own blood for potential use during surgery, which significantly reduces the risk of transfusion-related infections. This option directly addresses the client's concern about infection risk. Requesting a specific blood type from a donor (Choice B) is not as effective in reducing infection risk compared to autologous blood donation. Using blood from a family member (Choice C) carries the risk of transfusion reactions and infections due to compatibility issues. Accepting allogeneic blood without concerns (Choice D) does not address the client's specific concern about infection risk and is not the most appropriate option in this situation.

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