Nursing Elites

1. To ensure the safety of a client receiving a continuous intravenous normal saline infusion, how often should the LPN change the administration set?

• A. Every 4 to 8 hours
• B. Every 12 to 24 hours
• C. Every 24 to 48 hours
• D. Every 72 to 96 hours

Correct answer: D

Rationale: The correct answer is to change the administration set every 72 to 96 hours. This practice helps reduce the risk of infection by preventing the build-up of bacteria in the tubing. Changing the set too frequently (choices A, B, and C) may increase the chances of contamination and infection without providing additional benefits. Therefore, the LPN should follow the guideline of changing the administration set every 72 to 96 hours to maintain the client's safety during the continuous intravenous normal saline infusion.

2. A client admitted with abdominal pain tells the nurse that her father died recently, and she begins crying while talking about him. The nurse determines that the client’s temperature is 39.2°C (102.6°F), her abdomen is soft without tenderness, and her menses are overdue by 2 days. To which observation should the nurse give priority attention?

• A. The client’s temperature
• B. The client’s menses are overdue
• C. The client’s crying
• D. The client’s soft abdomen

Correct answer: B

Rationale: The correct answer is B. An overdue menses might indicate a potential cause of abdominal pain, especially in the context of recent emotional stress. While the client's temperature, crying, and soft abdomen are important observations, the priority should be given to the overdue menses as it could provide crucial information related to the abdominal pain and the client's overall health status. The emotional distress may have a secondary impact on the physical symptoms, making the menstrual status a critical observation to address first.

3. The patient is reporting an inability to clear nasal passages. Which action will the nurse take?

• A. Use gentle suction to prevent tissue damage.
• B. Instruct the patient to blow their nose forcefully to clear the passage.
• C. Place a dry washcloth under the nose to absorb secretions.
• D. Insert a cotton-tipped applicator into the back of the nose.

Correct answer: A

Rationale: When a patient reports an inability to clear nasal passages, the appropriate action for the nurse to take is to use gentle suction to prevent tissue damage. Suctioning helps remove excess mucus or secretions without causing harm to the nasal tissues. Instructing the patient to blow their nose forcefully (Choice B) may exacerbate the issue and cause discomfort or injury. Placing a dry washcloth under the nose (Choice C) is not an effective intervention for clearing nasal passages. Inserting a cotton-tipped applicator into the back of the nose (Choice D) is not recommended as it can be invasive and may cause injury or discomfort to the patient.

4. A healthcare professional is caring for a client who has a prescription for a vest restraint. Which of the following actions should the healthcare professional take?

• A. Tie the restraint with a quick-release knot.
• B. Use a slipknot to secure the restraint.
• C. Ensure the restraint is tightly secured.
• D. Attach the restraint to the bed frame.

Correct answer: A

Rationale: The correct action for the healthcare professional to take when applying a vest restraint is to tie it with a quick-release knot. A quick-release knot allows for easy and rapid removal in case of an emergency, ensuring the safety of the client. Using a slipknot (Choice B) is not recommended as it may not provide quick release in emergencies. Ensuring the restraint is tightly secured (Choice C) can be dangerous as it can restrict circulation or cause discomfort. Attaching the restraint to the bed frame (Choice D) is inappropriate and can lead to potential harm or injury to the client.

5. When explaining the fecal occult blood testing procedure to a client, which of the following information should be included?

• A. Eating more protein is not necessary before testing.
• B. Multiple stool specimens may be required for testing.
• C. A red color change indicates a positive test.
• D. The specimen must not be contaminated with urine.

Correct answer: D

Rationale: The correct answer is D. When performing fecal occult blood testing, it is crucial to inform the client that the specimen must not be contaminated with urine to prevent false results. Choices A and B are incorrect because eating more protein is not required before testing, and multiple stool specimens may be necessary for accurate results, respectively. Additionally, regarding choice C, a red color change, not blue, indicates a positive test result, making it an incorrect option.

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