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. A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, they note that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?

• A. Check the IV tubing for obstruction
• B. Increase the infusion rate
• C. Administer a bolus of fluid
• D. Replace the IV catheter

Correct answer: A

Rationale: The correct first action for the nurse to take in this situation is to check the IV tubing for obstruction. By doing this, the nurse can assess if there is any blockage or kink in the tubing that is impeding the flow of the IV solution. This step is crucial as it helps in identifying the reason for the inadequate infusion rate. Increasing the infusion rate (Choice B) without first checking for obstructions can lead to potential complications if there is a blockage. Administering a bolus of fluid (Choice C) may not be appropriate without addressing the cause of the decreased infusion rate. Similarly, replacing the IV catheter (Choice D) is not the initial priority unless obstruction is ruled out and other troubleshooting measures have been taken.

3. An elderly client who requires frequent monitoring fell and fractured a hip. Which LPN/LVN is at greatest risk for a malpractice judgment?

• A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
• B. The nurse assigned to care for the client who was at lunch at the time of the fall.
• C. The nurse who transferred the client to the chair when the fall occurred.
• D. The charge nurse who completed rounds 30 minutes before the fall occurred.

Correct answer: C

Rationale: The nurse who transferred the client to the chair when the fall occurred is directly involved in the event that led to the injury. Improper transfer techniques or lack of appropriate precautions during the transfer could have contributed to the fall and subsequent fracture of the hip. This direct involvement makes this nurse the one at greatest risk for a malpractice judgment. Choices A, B, and D are not as directly linked to the event that caused the injury. While poor nursing notes could be a factor, it is the immediate action of transferring the client that has a more direct impact on the client's fall and subsequent injury.

4. A group of newly licensed nurses is being taught about the Braden Scale by a nurse. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

• A. “The client’s age is not a factor in the measurement.”
• B. “The scale measures six elements.”
• C. “A lower score indicates a higher risk of pressure ulcers.”
• D. “Each element is scored on a range from 1 to 4 points.”

Correct answer: B

Rationale: Choice B is the correct answer because the Braden Scale measures six elements: Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction, and Shear. The other choices are incorrect because: Choice A states that the client's age is not a factor in the measurement, which is accurate as age is not included in the Braden Scale. Choice C incorrectly states that a lower score indicates a higher risk of pressure ulcers, which is the opposite of how the Braden Scale works. Choice D inaccurately describes the scoring range of each element on the Braden Scale, which is not from 1 to 4 points but rather from 1 to 3.

5. A client with amphetamine toxicity and sensory overload is being cared for by a nurse. Which intervention should the nurse implement?

• A. Immediately conduct a thorough assessment.
• B. Encourage visitors to distract the client.
• C. Provide a private room and limit stimulation.
• D. Speak softly to the client.

Correct answer: C

Rationale: The most appropriate intervention for a client with amphetamine toxicity and sensory overload is to provide a private room and limit stimulation. This approach helps reduce external stimuli, which can exacerbate sensory overload, and creates a calming environment for the client. Encouraging visitors to distract the client may worsen sensory overload by adding more stimulation. Speaking softly, rather than at a higher volume, is more suitable to help maintain a calm environment. Therefore, the correct choice is to provide a private room and limit stimulation (option C) in this scenario.

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