Nursing Elites

1. How should the LPN document pain for a non-verbal client using the FLACC pain scale with these findings?

• A. 1
• B. 4
• C. 3
• D. 2

Correct answer: B

Rationale: The correct answer is B: '4'. The FLACC pain scale assesses pain in non-verbal patients based on five categories: Face, Legs, Activity, Cry, and Consolability. In this case, the client exhibits occasional grimacing (1 point), relaxed legs (0 points), squirming (1 point), moans and whimpers (1 point), and is distractible (1 point). Adding these points together results in a total pain score of 4. Therefore, the LPN should document a pain score of 4 for this non-verbal client. Choices A, C, and D are incorrect as they do not accurately reflect the total pain score based on the given findings.

2. When placing a Foley catheter in a female client, what is the correct order of steps?

• A. E, A, F, B, C, G, D
• B. A, E, B, F, G, D, C
• C. A, E, F, B, C, G, D
• D. E, A, F, B, C, G, D

Correct answer: D

Rationale: The correct order for placing a Foley catheter in a female client is as follows: E. Place the client in a supine position with flexed knees, A. Prepare the sterile field, F. Place lubricant on the catheter, B. Separate labia with the non-dominant hand, C. Clean the urinary meatus using cleansing solutions and forceps, G. Place the catheter in the meatus with the dominant (sterile) hand, and D. Inflate the catheter balloon. This sequence ensures proper hygiene, patient comfort, and reduces the risk of infection. Incorrect sequences could compromise sterility, cause discomfort, and increase the risk of infection. Therefore, the correct answer is E, A, F, B, C, G, D.

3. A nurse is assisting a new nursing graduate with organizational skills in delivering client care. The nurse determines that the new nursing graduate needs assistance with time management if the new graduate takes which action?

• A. Gathers supplies before beginning a task
• B. Allows time for unexpected tasks
• C. Prioritizes client needs and daily tasks
• D. Documents task completion and client information at the end of the day

Correct answer: A

Rationale: The correct answer is 'Gathers supplies before beginning a task.' This action indicates a lack of effective time management because gathering supplies before starting a task can lead to inefficiency and time wastage. Effective time management involves organizing tasks efficiently, which includes having all necessary supplies ready before initiating a task. Allowing time for unexpected tasks, prioritizing client needs and daily tasks, and documenting task completion and client information at the end of the day are all essential components of good time management practices. Therefore, the new nursing graduate should focus on improving the timing of supply gathering to enhance time management skills. The other choices are not indicative of poor time management; instead, they demonstrate important aspects of effective time management in client care delivery.

4. To remove hard contact lenses from an unresponsive client, what should the nurse do?

• A. Gently irrigate the eye with an irrigating solution from the inner canthus outward
• B. Grasp the lens with a gentle pinching motion
• C. Don sterile gloves before attempting the procedure
• D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens

Correct answer: D

Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.

5. The nurse provides a postoperative client with an analgesic medication and darkens the room before the client goes to sleep for the night. The nurse's actions:

• A. help decrease stimuli from the cerebral cortex.
• B. stimulate hormonal changes in the brain.
• C. help the client's circadian rhythm.
• D. alert the hypothalamus in the brain.

Correct answer: A

Rationale: The nurse's actions of providing an analgesic medication and darkening the room aim to decrease stimuli from the cerebral cortex. Reduction of environmental stimuli, especially light and noise, from the cerebral cortex, which is an area of arousal, facilitates sleep. By decreasing input to this area, the client is more likely to fall asleep and stay asleep. Choices B, C, and D are incorrect because the scenario does not involve stimulating hormonal changes, influencing the circadian rhythm, or alerting the hypothalamus.

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