Nursing Elites

1. Which action should the PN implement when using standard precautions to provide client care?

• A. Apply sterile gloves to obtain a finger stick blood sample
• B. Wear clean exam gloves to perform perineal catheter care
• C. Replace the needle cap after giving an intramuscular injection
• D. Wear a paper gown to prevent transmission of droplet pathogens

Correct answer: B

Rationale: The correct answer is B. When using standard precautions, healthcare providers should wear clean exam gloves to perform perineal catheter care. This approach helps prevent the transmission of pathogens and ensures the safety of both the client and the healthcare provider. Choice A is incorrect because applying sterile gloves for a finger stick blood sample is unnecessary when non-sterile gloves would suffice. Choice C is incorrect because replacing the needle cap after giving an intramuscular injection is not directly related to standard precautions. Choice D is incorrect because wearing a paper gown is not a standard precaution for preventing the transmission of droplet pathogens.

2. A client who had a hip replacement is being prepared for discharge. What should the nurse include in the discharge teaching to prevent hip dislocation?

• A. Avoid crossing your legs at the knees or ankles.
• B. Do not sleep on the side of the hip that was operated on.
• C. Sit in high chairs and keep your knees higher than your hips.
• D. Do not bend forward at the waist to pick up objects.

Correct answer: A

Rationale: The correct answer is A: 'Avoid crossing your legs at the knees or ankles.' Crossing legs at the knees or ankles can cause excessive stress on the new hip joint, leading to a risk of dislocation. Choice B is incorrect because sleeping on the side of the operated hip can also increase the risk of dislocation. Choice C is incorrect as sitting in low chairs with knees higher than hips is a recommended position to prevent hip dislocation. Choice D is incorrect because bending forward at the waist to pick up objects can strain the hip joint and increase the risk of dislocation.

3. After spinal fusion surgery, a client reports numbness and tingling in the legs. What should the nurse do first?

• A. Assess the client’s neurovascular status in the lower extremities.
• B. Reposition the client to relieve pressure on the spine.
• C. Administer prescribed pain medication.
• D. Notify the healthcare provider immediately.

Correct answer: A

Rationale: After spinal fusion surgery, numbness and tingling in the legs may indicate nerve compression or damage. The priority action for the nurse is to assess the client’s neurovascular status in the lower extremities. This assessment will help determine the cause and severity of the symptoms, guiding further interventions. Repositioning the client may be necessary for comfort, but assessing neurovascular status is the initial step. Administering pain medication should only follow the assessment to address any discomfort. Notifying the healthcare provider immediately is not the first action unless there are emergent signs requiring urgent intervention.

4. The practical nurse is caring for a client who had a total laryngectomy, left radical neck dissection, and tracheostomy. The client is receiving nasogastric tube feedings via an enteral pump. Today the rate of feeding is increased from 50 ml/hr to 75 ml/hr. What parameter should the PN use to evaluate the client's tolerance to the rate of the feeding?

• A. Daily weight
• B. Gastric residual volumes
• C. Bowel sounds
• D. Urinary and stool output

Correct answer: B

Rationale: Monitoring gastric residual volumes helps to assess how well the client is tolerating the increased feeding rate. High residuals may indicate delayed gastric emptying, which could lead to complications like aspiration. This helps in adjusting the feeding plan as necessary. Daily weight (Choice A) is not the most appropriate parameter to evaluate tolerance to feeding rate changes. Bowel sounds (Choice C) and urinary/stool output (Choice D) are important assessments but do not directly indicate tolerance to enteral feeding rate changes.

5. A client on bedrest refuses to wear the prescribed pneumatic compression devices after surgery. Which action should the PN implement in response to the client's refusal?

• A. Emphasize the importance of active foot flexion
• B. Check the surgical dressing
• C. Complete an incident report
• D. Explain the use of an incentive spirometer every 2 hours

Correct answer: A

Rationale: The correct action for the PN to implement when a client refuses pneumatic compression devices is to emphasize the importance of active foot flexion. Active foot flexion exercises can help prevent deep vein thrombosis (DVT) in clients who are not using the compression devices. Encouraging some form of circulation-promoting activity is crucial to reduce the risks associated with immobility. Checking the surgical dressing (Choice B) is important but not the immediate action to address the refusal of compression devices. Completing an incident report (Choice C) is not necessary in this situation as the client's refusal is not an incident. Explaining the use of an incentive spirometer (Choice D) is not directly related to addressing the refusal of compression devices for DVT prevention.

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