Nursing Elites

1. While changing the linen on the client's bed, what should the nurse do?

• A. Hold the linen away from their body and clothing.
• B. Fold the linen neatly before placing it in the laundry.
• C. Wear clean gloves while handling the linen.
• D. Place the linen directly on the floor until the new linen is in place.

Correct answer: A

Rationale: When changing the linen on a client's bed, it is essential for the nurse to hold the linen away from their body and clothing. This practice helps prevent contamination and maintain a clean environment. Folding the linen neatly before placing it in the laundry (Choice B) is a good practice but not the immediate action required during linen changing. Wearing clean gloves while handling the linen (Choice C) is important in certain situations but may not be necessary for routine linen changing. Placing the linen directly on the floor until the new linen is in place (Choice D) is incorrect as it can lead to contamination and is not hygienic.

2. The clinician is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing?

• A. Covering the wound with a dry dressing
• B. Using hydrogen peroxide soaks
• C. Leaving the area open to dry
• D. Applying a hydrocolloid or foam dressing

Correct answer: D

Rationale: Applying a hydrocolloid or foam dressing is the most effective treatment to promote healing for a Stage 2 skin ulcer. These dressings create a moist environment that supports healing and prevents further tissue damage. Option A (covering the wound with a dry dressing) can lead to drying out the wound bed, hindering healing. Option B (using hydrogen peroxide soaks) can be too harsh and may damage the surrounding healthy tissue. Option C (leaving the area open to dry) can delay healing as it does not provide the necessary moist environment for optimal wound healing.

3. A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding 'stronger pain medications.' What initial action is most important for the LPN/LVN to take?

• A. Ask about any past history of drug abuse or addiction.
• B. Measure the pulse volume and capillary refill distal to the infiltration.
• C. Compress the infiltrated tissue to measure the degree of edema.
• D. Evaluate the extent of ecchymosis over the forearm area.

Correct answer: B

Rationale: The most important initial action for the LPN/LVN to take in this situation is to measure the pulse volume and capillary refill distal to the infiltration. This assessment helps evaluate the severity of the infiltration and the circulation in the affected arm. Asking about past history of drug abuse or addiction (Choice A) is not the priority when addressing acute arm pain and infiltration. Compressing the infiltrated tissue (Choice C) may exacerbate the pain and is not recommended as the first step. Evaluating the extent of ecchymosis (Choice D) is not as critical as assessing the circulation in the affected arm, which is better addressed by measuring pulse volume and capillary refill.

4. During auscultation of a client experiencing chest pain worsened by inspiration, a nurse hears a high-pitched scratching sound in both systole and diastole with the diaphragm of the stethoscope placed at the left sternal border. Which of the following heart sounds should the nurse document?

• A. Pericardial friction rub
• B. Murmur
• C. S1 and S2
• D. Bruit

Correct answer: A

Rationale: The correct answer is 'Pericardial friction rub.' A pericardial friction rub is a high-pitched, scratching sound heard in both systole and diastole, which is characteristic of pericardial inflammation. This sound is different from a murmur, which is a swooshing or blowing sound due to turbulent blood flow. S1 and S2 are normal heart sounds, and a bruit is a whooshing sound caused by turbulent blood flow in an artery, not related to pericardial inflammation.

5. Upon completing the admission documents, the nurse learns that the 87-year-old client does not have an advance directive. What action should the nurse take?

• A. Record the lack of advance directive on the chart
• B. Give information about advance directives
• C. Assume that the client wishes a full code
• D. Refer this issue to the unit secretary

Correct answer: B

Rationale: The correct action for the nurse to take is to give information about advance directives to the client. By providing this information, the nurse empowers the client to make an informed decision about their care preferences. Choice A is incorrect because simply recording the lack of advance directive does not address the client's need for information. Choice C is incorrect because assuming the client wishes a full code without discussing it with them is not appropriate and may not align with the client's wishes. Choice D is incorrect as the nurse should directly address the issue with the client rather than involving another staff member.

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