Nursing Elites

1. Which task should not be performed by the licensed practical nurse?

• A. Inserting a Foley catheter
• B. Discontinuing a nasogastric tube
• C. Obtaining a sputum specimen
• D. Initiating a blood transfusion

Correct answer: D

Rationale: A licensed practical nurse should not initiate a blood transfusion. LPNs can assist with transfusions and verify ID numbers but should not be assigned to initiate the procedure. Inserting Foley catheters, discontinuing nasogastric tubes, and obtaining sputum specimens are within the scope of practice for LPNs. Therefore, options A, B, and C are tasks that LPNs can perform, making them incorrect choices.

2. What significant event occurs in the orientation phase of a nurse-client relationship?

• A. establishment of roles
• B. identification of transference phenomenon
• C. placement of the client within their family structure
• D. client agreement that the nurse has the authority in the relationship

Correct answer: B

Rationale: In the orientation phase of a nurse-client relationship, the significant event is the identification of transference phenomenon. Transference phenomena are intensified in relationships with authority figures like nurses and physicians. Positive transferences may include a desire for affection and dependency, while negative transferences may involve hostility and competitiveness. It is crucial to recognize and address these transferences before progress and positive changes can be made in the working stage. The other choices are incorrect; the establishment of roles may occur in the working phase, placing the client within their family structure is not a key event in the orientation phase, and client agreement on the nurse's authority is not the primary focus during this phase.

3. A client with cancer is to undergo an intravenous pyelogram. The nurse should:

• A. Ensure adequate fluid intake 24 hours before the procedure
• B. Ask the client to void immediately before the study
• C. Administer medication that affects the central nervous system as prescribed
• D. Position the client appropriately for the procedure

Correct answer: B

Rationale: The correct answer is to ask the client to void immediately before the study. For an intravenous pyelogram, the client may have orders for laxatives or enemas, so ensuring the client voids before the test is important to prevent obscuring visualization of the kidney, ureters, and bladder. Choice A is incorrect because there is no need to force fluids before the procedure. Choice C is incorrect as medications affecting the central nervous system should not be held unless specified by the healthcare provider. Choice D is incorrect as covering the reproductive organs with an x-ray shield is not necessary for an intravenous pyelogram.

4. An elderly client denies that abuse is occurring. Which of the following factors could be a barrier for the client to admit being a victim?

• A. knowledge that elder abuse is rare
• B. personal belief that abuse is deserved
• C. lack of developmentally appropriate screening tools
• D. fear of reprisal or further violence if the incident is reported

Correct answer: D

Rationale: Barriers to reporting elder abuse include victim shame, fear of reprisals, fear of loss of caregiver, and lack of knowledge of agencies that provide services. Many elders fear that reporting abuse results in their placement in long-term care because the current caregiver is the abuser. Choice A is incorrect because knowledge of the frequency of elder abuse is not a significant factor in a victim's reluctance to report. Choice B is also incorrect; while some victims may have feelings of undeservedness, it is not a common primary barrier to reporting abuse. Choice C is incorrect as the lack of appropriate screening tools may hinder identification but is not a significant barrier for the client to admit being a victim. Therefore, the correct answer is D, as the fear of reprisal or further violence if the incident is reported is a common and significant barrier for elderly clients to admit being a victim.

5. When assessing a client with glaucoma, a nurse expects which of the following findings?

• A. Complaints of double vision
• B. Complaints of halos around lights
• C. Intraocular pressure of 15 mm Hg
• D. Soft globe on palpation

Correct answer: B

Rationale: When assessing a client with glaucoma, a common finding is complaints of halos around lights. Other symptoms of glaucoma include loss of peripheral vision or blind spots, reddened sclera, firm globe, decreased accommodation, and occasional eye pain. Glaucoma may be asymptomatic until permanent damage to the optic nerve and retina occurs. Double vision is not a typical symptom of glaucoma. In terms of intraocular pressure, normal levels range from 10 to 21 mm Hg, making an intraocular pressure of 15 mm Hg within the normal range. A soft globe on palpation is not a typical finding in glaucoma.

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