Nursing Elites

1. A client complains of pain in their leg, and the nurse notes swelling and pallor. What is the priority nursing action?

• A. Administer pain medication.
• B. Elevate the limb and monitor closely.
• C. Encourage movement to reduce swelling.
• D. Notify the provider immediately about the symptoms.

Correct answer: D

Rationale: The correct answer is D: Notify the provider immediately about the symptoms. Swelling and pallor in a limb can be indicative of serious circulatory issues or compartment syndrome. It is crucial to inform the healthcare provider promptly to assess and address the situation. Administering pain medication (choice A) may temporarily alleviate the symptoms but does not address the underlying cause. Elevating the limb and monitoring closely (choice B) can be beneficial but does not replace the need for immediate professional evaluation. Encouraging movement to reduce swelling (choice C) is contraindicated in this scenario as it may worsen the condition if a circulatory issue or compartment syndrome is present.

2. The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?

• A. I should call 911 if my grandchild loses consciousness.
• B. Never induce vomiting if my grandchild drinks bleach.
• C. If my grandchild eats a plant, I should provide syrup of ipecac.
• D. The number for poison control is 800-222-1222.

Correct answer: C

Rationale: The correct answer is C. Administering syrup of ipecac is no longer recommended in cases of poisoning. This is because it can lead to complications and is not considered safe. The grandparent should be informed that syrup of ipecac should not be given to a child who has ingested a toxic substance. Choices A, B, and D provide accurate information regarding actions to take in case of poisoning, such as calling 911 if the child loses consciousness, not inducing vomiting if the child drinks bleach, and having the poison control number readily available.

3. A patient has impaired skin integrity, and a nurse is providing care. What action should the nurse take to promote healing?

• A. Apply a dry, sterile dressing to the wound.
• B. Use sterile saline to clean the wound.
• C. Apply a warm compress to promote circulation.
• D. Keep the wound open to air for faster healing.

Correct answer: B

Rationale: The correct action to promote healing in a patient with impaired skin integrity is to use sterile saline to clean the wound. Sterile saline helps prevent infection and promotes healing of wounds by keeping the area clean. Applying a dry, sterile dressing (Choice A) may not be effective as it does not address the need for wound cleaning. Applying a warm compress (Choice C) may not be suitable for all types of wounds and could potentially cause harm. Keeping the wound open to air (Choice D) is generally not recommended as it can lead to infection and slow down the healing process.

4. A case manager at an assisted living facility is reviewing the use of complementary health practices by several clients. Which of the following actions should the case manager plan to take?

• A. Plan to report a client's use of echinacea to the provider as a contraindication to aspirin therapy
• B. Plan to schedule time for a new client to continue tai chi practice as a stress reduction technique
• C. Tell a client that yoga has not been proven effective to reduce manifestations of menopause
• D. Tell a client who drinks cranberry juice daily that it can help treat existing urinary tract infections

Correct answer: B

Rationale: The correct answer is B. Tai chi is a recognized complementary health practice for stress reduction. Scheduling time for a new client to continue tai chi practice aligns with supporting holistic care. Choice A is incorrect because reporting a client's use of echinacea as a contraindication to aspirin therapy is not necessary without further context or evidence of interactions. Choice C is wrong because yoga can indeed be effective in reducing manifestations of menopause. Choice D is also incorrect because while cranberry juice is known to help prevent urinary tract infections, it is not typically used to treat existing infections.

5. A charge nurse on a medical-surgical unit is preparing to delegate tasks to a licensed practical nurse (LPN). Which of the following tasks should the charge nurse delegate to the LPN?

• A. Administering an oral antibiotic to a client
• B. Performing an admission assessment of a client
• C. Creating new teaching for a guardian of a toddler
• D. Administering IV conscious sedation to a client

Correct answer: A

Rationale: Administering oral antibiotics is within the scope of practice for an LPN and can be safely delegated. LPNs are trained to administer medications, including oral ones. Performing an admission assessment (Choice B) involves critical thinking and comprehensive evaluation, typically done by registered nurses. Creating new teaching material (Choice C) requires specialized knowledge and is usually the responsibility of a nurse with additional training in education. Administering IV conscious sedation (Choice D) is a high-risk task that requires advanced skills and should be performed by a registered nurse or higher-level provider.

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