Nursing Elites

1. Why might breast implants interfere with mammography?

• A. They might cause additional discomfort.
• B. They are contraindications to mammography.
• C. They are likely to be dislodged.
• D. They might prevent detection of masses.

Correct answer: D

Rationale: Breast implants can interfere with mammography by potentially preventing the detection of masses. The presence of implants can obscure a clear view of breast tissue, making it difficult to identify abnormalities such as masses that may indicate breast cancer. Choices A, B, and C are incorrect because discomfort, contraindications, and dislodgment are not primary reasons why breast implants interfere with mammography. The main concern is the impedance of detecting abnormalities accurately due to the implants.

2. Which of the following clients would be most appropriate for an LPN to assign to a nursing assistant?

• A. an 18-year-old client with a femur fracture who is just returning to the floor from the recovery unit
• B. an 84-year-old client 2 days post-op after knee replacement surgery who needs help ambulating
• C. a 35-year-old client who is suffering from an acute asthma attack
• D. a 20-year-old client with Cystic Fibrosis who needs an early morning sputum sample collection

Correct answer: D

Rationale: Collecting sputum samples on stable clients is within the scope of practice for an LPN. This task does not require immediate intervention or assessment by an RN or medical provider. An RN should perform the initial assessment on any client immediately post-op as it requires a higher level of assessment and monitoring. A client suffering from an acute asthma attack should be attended to by an RN or medical provider due to the potential severity and need for prompt intervention. Assigning a medically stable client who needs help ambulating to a nursing assistant is appropriate as it falls within their scope of practice and allows the LPN to focus on tasks that require their expertise.

3. For a client requiring total oral care, it is important for the nurse to:

• A. assemble all equipment, assist the client to a semi-Fowler's position, and place a towel on his chest.
• B. place the client in Fowler's position, prepare the equipment, and instruct the client what to do.
• C. assemble all equipment, place the client in a side-lying position, and place a towel under his chin.
• D. use gloves and clean the client's mouth, including the tongue.

Correct answer: C

Rationale: To provide total oral care to a client, the nurse should first assemble all necessary equipment. Placing the client in a side-lying position helps fluids to easily flow out or pool in the side of the mouth for suctioning, thus preventing aspiration. Additionally, placing a towel under the client's chin and a curved basin against the chin helps to maintain cleanliness during the procedure. Choice A is incorrect because the client should be placed in a side-lying position, not a semi-Fowler's position which is used for respiratory issues. Choice B is incorrect as it does not emphasize the importance of proper positioning for effective oral care. Choice D is incorrect as it oversimplifies the procedure by focusing only on cleaning the mouth without considering the importance of positioning and preparation.

4. When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?

• A. grief work facilitation
• B. vital signs monitoring
• C. medication administration: skin
• D. anxiety reduction

Correct answer: A

Rationale: The correct answer is 'grief work facilitation' because it is a nursing intervention classification specifically designed to address disturbed body image in burn clients. The expected outcome of this intervention is grief resolution, which can help the client cope with the body image changes resulting from the burn. Choice B, 'vital signs monitoring,' is not the appropriate intervention for body image disturbance in burn clients. Vital signs monitoring is typically used for assessing physiological parameters like blood pressure, pulse rate, and temperature. Choice C, 'medication administration: skin,' is more focused on treating skin-related issues rather than addressing body image disturbance. It involves the administration of medications to promote skin healing and integrity. Choice D, 'anxiety reduction,' is aimed at managing anxiety in clients with major burns and is not specifically targeted at addressing body image disturbance. While anxiety may be a common emotional response to burns, the most appropriate intervention for body image disturbance in this scenario is 'grief work facilitation.'

5. The nurse is preparing to administer the 9 am dose of IV antibiotics when she notes the IVAC cord is frayed with wiring visible. What action should be her priority for this client?

• A. Notify maintenance to come and check the pump immediately.
• B. Continue with the administration of the antibiotic and fill out an equipment maintenance request.
• C. Immediately discontinue the use of this IVAC pump and obtain a replacement.
• D. Tag the equipment for maintenance.

Correct answer: C

Rationale: The correct action is to immediately discontinue the use of the IVAC pump and obtain a replacement because the frayed cord poses a safety risk to the client. Continuing to use the pump with visible wiring could lead to electric shock or other serious harm to the client. Notifying maintenance to come and check the pump immediately (Choice A) may cause unnecessary delays in ensuring the client's safety. Continuing with the administration of the antibiotic and filling out an equipment maintenance request (Choice B) is unsafe as it ignores the immediate danger. Tagging the equipment for maintenance (Choice D) does not address the urgent need to protect the client from harm.

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