Nursing Elites

1. What intervention is most important for the LPN/LVN to implement for a male client experiencing urinary retention?

• A. Apply a condom catheter.
• B. Apply a skin protectant.
• C. Encourage increased fluid intake.
• D. Assess for bladder distention.

Correct answer: D

Rationale: The most important intervention for the LPN/LVN to implement for a male client experiencing urinary retention is to assess for bladder distention. This assessment is crucial as it helps identify the underlying cause of urinary retention, such as bladder distention or obstruction. By assessing the bladder, the LPN/LVN can determine the appropriate interventions needed, such as catheterization, medication administration, or further evaluation by the healthcare provider. Applying a condom catheter (Choice A) is more suitable for urinary incontinence, not retention. Applying a skin protectant (Choice B) is typically done to prevent skin breakdown in incontinent clients. Encouraging increased fluid intake (Choice C) may be beneficial for some urinary issues but is not the priority intervention for urinary retention.

2. A healthcare professional is assessing a client’s extraocular eye movements. Which of the following should the professional do?

• A. Instruct the client to follow a finger through the six cardinal positions of gaze.
• B. Hold a finger 46 cm (18 in) away from the client’s eyes.
• C. Ask the client to cover their right eye during assessment of the left eye.
• D. Position the client 6.1 m (20 feet) away from the Snellen chart.

Correct answer: A

Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action when assessing extraocular eye movements. This technique assesses the movement of the eyes in all directions and helps to test cranial nerves 3, 4, and 6, which control eye movements. Choice B is incorrect as the distance mentioned is not relevant for assessing extraocular eye movements. Choice C is incorrect as both eyes need to be assessed independently. Choice D is incorrect as positioning the client 6.1 m (20 feet) away from the Snellen chart is related to visual acuity testing, not extraocular eye movements.

3. A healthcare provider is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the provider identify as an adverse effect of opioids?

• A. Urinary incontinence
• B. Diarrhea
• C. Bradypnea
• D. Orthostatic hypotension

Correct answer: D

Rationale: The correct answer is D: Orthostatic hypotension. Opioids can cause orthostatic hypotension, leading to a sudden drop in blood pressure when changing positions. This effect is due to the vasodilatory properties of opioids, which can result in decreased blood flow to the brain upon standing up. Choices A, B, and C are incorrect. Urinary incontinence and diarrhea are not typical adverse effects of opioids. Bradypnea, or slow breathing, is a potential side effect of opioid overdose or respiratory depression, but it is not a common adverse effect following normal opioid administration.

4. A client with heart failure and a new prescription for hydrochlorothiazide is receiving discharge teaching about safety considerations from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “I will take a hot bath before going to bed.”
• B. “I will take my new medication in the evening.”
• C. “I will leave a light on in my bathroom at night.”
• D. “I will weigh myself once weekly.”

Correct answer: C

Rationale: The correct answer is C. Leaving a light on in the bathroom at night is important for an older adult with heart failure who is taking hydrochlorothiazide, a diuretic that can cause nocturia. This safety measure helps prevent falls during nighttime bathroom visits. Option A is incorrect because taking a hot bath before bed can increase the risk of falls due to potential dizziness. Option B does not directly relate to safety considerations but rather the timing of medication administration. Option D, weighing oneself once weekly, is important for monitoring fluid retention but does not address safety concerns related to nocturia and falls.

5. The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take?

• A. Directly address the child instead of the mother.
• B. Continue asking the mother questions about the child.
• C. Request another nurse to interview the mother now.
• D. Politely ask the mother to look at you when answering.

Correct answer: B

Rationale: In this scenario, the LPN should continue asking the mother questions about the child. The mother's behavior of looking at the floor may be a cultural practice, such as avoiding direct eye contact, which should be respected. By maintaining the conversation with the mother, the nurse acknowledges and respects her communication style, fostering trust and open dialogue. Option A is not the best choice as it may disregard the cultural context and the importance of the mother's input. Option C is unnecessary as the LPN can effectively handle the situation. Option D could be perceived as insensitive and may disrupt the rapport between the nurse and the mother.

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