Nursing Elites

1. Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage?

• A. Insert an indwelling urinary catheter.
• B. Limit caloric and protein intake.
• C. Turn the patient every 2 hours.
• D. Assess for pain during a bath.

Correct answer: D

Rationale: The most important action for preventing skin impairment in a mobile patient with local nerve damage is to assess for pain during a bath. Assessing pain during a bath helps in evaluating sensory nerve function by checking for touch, pain, heat, cold, and pressure. This assessment is crucial in identifying areas of potential skin breakdown and implementing preventive measures. Inserting an indwelling urinary catheter (Choice A) is not directly related to preventing skin impairment in this context. Limiting caloric and protein intake (Choice B) is not pertinent to skin impairment prevention for a mobile patient with local nerve damage. While turning the patient every 2 hours (Choice C) is a good practice for preventing pressure ulcers, in this case, assessing for pain during a bath is more directly related to preventing skin impairment associated with nerve damage.

2. A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?

• A. Ask another nurse to observe the medication wastage
• B. Notify the pharmacy when wasting the medication
• C. Lock the remaining medication in the controlled substance cabinet
• D. Dispose of the vial with the remaining medication in a sharps container

Correct answer: A

Rationale: In medication wastage situations involving controlled substances, it is crucial to have a second nurse observe and verify the disposal process. This practice ensures accountability and prevents any mishandling or diversion of the medication. Choice B is incorrect because notifying the pharmacy is not the immediate action required in this scenario. Choice C is incorrect as locking the remaining medication in the controlled substance cabinet without proper witnessing does not ensure accountability. Choice D is incorrect as disposing of the vial with the remaining medication in a sharps container does not address the need for a witness to verify the wastage of the controlled substance.

3. During an assessment, a healthcare professional is evaluating a client who has been on bed rest for the past month. Which of the following findings should the healthcare professional identify as an indication that the client has developed thrombophlebitis?

• A. bladder distention
• B. decreased blood pressure
• C. calf swelling
• D. diminished bowel sounds

Correct answer: C

Rationale: Calf swelling, redness, and tenderness are classic signs of thrombophlebitis. The swelling occurs due to the formation of a blood clot in the deep veins of the calf, leading to inflammation and potential obstruction of blood flow. Bladder distention (Choice A) is more indicative of urinary retention, decreased blood pressure (Choice B) can be seen in conditions like shock, and diminished bowel sounds (Choice D) may suggest gastrointestinal issues, none of which are directly related to thrombophlebitis.

4. A healthcare provider is receiving a prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the healthcare provider clarify?

• A. Dietitian consult
• B. Speech therapy referral
• C. Oral suction at the bedside
• D. Clear liquids

Correct answer: D

Rationale: The correct answer is D: 'Clear liquids.' Clients with dysphagia following a stroke are at high risk of aspiration, and clear liquids have a higher risk of aspiration compared to thickened liquids. Therefore, the healthcare provider should clarify the prescription for clear liquids and consider recommending thickened liquids instead to reduce the risk of aspiration. Choice A, 'Dietitian consult,' is essential to ensure the client receives appropriate nutrition tailored to their condition. Choice B, 'Speech therapy referral,' is crucial for dysphagia management and rehabilitation. Choice C, 'Oral suction at the bedside,' is a standard intervention to maintain airway patency and is not contraindicated in clients with dysphagia.

5. The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the LPN that this client understands the dietary restrictions?

• A. Tossed salad with low-sodium dressing, bacon, and tomato sandwich.
• B. New England clam chowder, unsalted crackers, fresh fruit salad.
• C. Skim milk, turkey salad, roll, and vanilla ice cream.
• D. Macaroni and cheese, diet Coke, and a slice of cherry pie.

Correct answer: C

Rationale: The correct answer is C: Skim milk, turkey salad, roll, and vanilla ice cream. These items are low in sodium, making it a suitable meal for someone on a low-sodium diet. Skim milk, turkey salad, and vanilla ice cream are naturally low in sodium, while the roll can be selected as a low-sodium option. Choices A, B, and D contain items that are typically high in sodium, such as bacon, clam chowder, crackers, and cheese, making them unsuitable for a low-sodium diet.

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