Nursing Elites

1. When assessing a client with amyotrophic lateral sclerosis (ALS), the nurse should expect which of the following findings?

• A. mental confusion
• B. muscular weakness
• C. sensory loss
• D. emotional liability

Correct answer: B

Rationale: Clients with ALS typically present with progressive muscular weakness and wasting as a hallmark feature of the disease. This weakness affects voluntary muscles, leading to challenges in mobility and daily activities. Sensory loss is not a characteristic feature of ALS, and individuals usually maintain their mental clarity without experiencing mental confusion. Emotional liability, characterized by sudden, uncontrolled changes in emotions, is not a common finding in ALS. While individuals may experience periods of grief due to the progressive nature of the disease, emotional liability is not a usual manifestation. Therefore, the correct finding to expect when assessing a client with ALS is muscular weakness.

2. The LPN is caring for a 32-year-old female client who is 8 hours post-op after a tonsillectomy. Which of these actions would be appropriate for the nurse to take?

• A. Inform the client that ear pain may occur and is normal.
• B. Provide ice water and a straw to promote easy fluid consumption.
• C. Provide hot tea to soothe the throat.
• D. Monitor vitals every 15 minutes.

Correct answer: A

Rationale: The appropriate action for the nurse to take is to inform the client that ear pain may occur and is normal after a tonsillectomy. Referred pain in the ear is common due to related nerve pathways. It is essential to educate the client about this to alleviate concerns. Providing ice water and a straw is not recommended as they may irritate the throat and disturb the healing process. Hot beverages like tea should also be avoided for the same reason. While monitoring vitals every 15 minutes is crucial in the immediate postoperative period for early identification of any complications, it is not the most appropriate action in this scenario where addressing the client's concerns and providing education is key.

3. Which of the following statements by a client indicates adequate preparation for magnetic resonance imaging?

• A. "I should wear earplugs during the test."?
• B. "I should remove my metal jewelry before the test."?
• C. "I should inform the healthcare provider about my pacemaker."?
• D. "I should inform the healthcare provider about my artificial hip."?

Correct answer: A

Rationale: The correct statement is, '"I should wear earplugs during the test,"?' as MRI scanners produce loud noises requiring ear protection. Metal objects, including jewelry, are not allowed inside the MRI room due to safety concerns related to the magnetic field. Choices B, C, and D are incorrect. Choice B is wrong because metal objects, including jewelry, are not permitted in the MRI room. Choices C and D are incorrect as having a pacemaker or an artificial hip raises concerns due to the magnetic field in MRI, requiring special precautions or considerations. It is crucial for individuals with such implants to inform their healthcare provider to assess the risks and determine the appropriate course of action.

4. The LPN is preparing to clean a client's PEG tube.The following tasks should the nurse perform EXCEPT?

• A. Gently remove crusty drainage from the site.
• B. Pull the tube in multiple directions to ensure it is secure.
• C. Thoroughly dry the skin around the tube site with a clean towel.
• D. Use mild soap to clean around the tube site.

Correct answer: B

Rationale: When cleaning a client's PEG tube, the nurse should perform tasks that focus on gentle cleaning and avoiding potential irritants. Choice A is correct as gently removing crusty drainage helps maintain hygiene. Choice C is important to prevent skin irritation and infection. Choice D is appropriate for cleaning the area. Choices B and D are incorrect. Choice B is incorrect because pulling the tube in multiple directions can lead to dislodgement or injury. Choice B is incorrect as talcum powder may irritate the stoma, and it is generally not recommended near PEG tubes.

5. How is the information documented on incident reports used?

• A. to analyze risk categories
• B. to ensure compliance with regulations
• C. to identify staff's educational needs
• D. all of the above

Correct answer: D

Rationale: The information documented on incident reports is used for various purposes, including analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs. Incident reports provide valuable data that can be utilized in risk management, quality monitoring, and improvement programs. Therefore, the correct answer is 'all of the above.' Choices A, B, and C are all correct as incident reports are used for analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs, respectively. Thus, the most comprehensive answer is 'all of the above.'

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