Nursing Elites

1. A client with a history of seizures is prescribed phenytoin (Dilantin). Which statement should the LPN/LVN include when teaching the client about this medication?

• A. Do not take the medication with milk to avoid reduced absorption.
• B. Brush and floss your teeth regularly to prevent gum disease.
• C. Avoid taking antacids within 2 hours of the medication.
• D. Report any unusual bleeding or bruising to the healthcare provider.

Correct answer: C

Rationale: The correct answer is to avoid taking antacids within 2 hours of phenytoin. Antacids can interfere with the absorption of phenytoin, reducing its effectiveness. Choice A is incorrect because phenytoin should not be taken with milk, as it may decrease its absorption. Choice B is unrelated to the medication and focuses on dental hygiene. Choice D is important but not directly related to phenytoin; it is more relevant to monitoring for adverse effects of the medication.

2. While caring for a client who is postoperative and has refused to use an incentive spirometer following major abdominal surgery, what is the nurse's priority action?

• A. Request that a respiratory therapist discuss the technique for using the incentive spirometer
• B. Determine the reasons why the client is refusing to use the incentive spirometer
• C. Document the client's refusal to participate in health restorative activities
• D. Administer a pain medication to the client

Correct answer: B

Rationale: The nurse's priority is to determine the reasons why the client is refusing to use the incentive spirometer. By understanding the client's concerns or barriers, the nurse can address them appropriately. Requesting a respiratory therapist (Choice A) may be necessary later but is not the priority. Documenting the refusal (Choice C) is important but does not address the immediate need to assess and intervene. Administering pain medication (Choice D) without addressing the root cause of refusal is not appropriate and may mask the issue rather than resolve it.

3. The LPN is instructing a client with high cholesterol about diet and lifestyle modifications. What comment from the client indicates that the teaching has been effective?

• A. If I exercise at least twice weekly for one hour, I will lower my cholesterol.
• B. I need to avoid eating proteins, including red meat.
• C. I will limit my intake of beef to 4 ounces per week.
• D. My blood level of low-density lipoproteins needs to increase.

Correct answer: C

Rationale: The correct answer is C. Limiting intake of beef to 4 ounces per week is an effective dietary modification to manage high cholesterol. Choice A is incorrect because the frequency and duration of exercise alone may not be sufficient to lower cholesterol significantly. Choice B is incorrect as proteins, including lean sources like poultry and fish, can be a part of a healthy diet. Choice D is incorrect as low-density lipoproteins, known as bad cholesterol, should be decreased, not increased, for heart health.

4. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that are associated with this problem include which of these?

• A. Lymphedema and nerve palsy
• B. Hearing loss and ataxia
• C. Headaches and vomiting
• D. Abdominal mass and weakness

Correct answer: D

Rationale: Neuroblastoma, a common solid tumor in children, often presents with symptoms related to the mass effect it causes. Abdominal mass and weakness are classic signs of neuroblastoma due to the tumor originating in the adrenal glands near the kidneys and potentially compressing nearby structures. Lymphedema and nerve palsy (Choice A) are not typically associated with neuroblastoma. Hearing loss and ataxia (Choice B) are more common in conditions affecting the central nervous system rather than neuroblastoma. Headaches and vomiting (Choice C) are nonspecific symptoms and are less commonly linked to neuroblastoma compared to the characteristic abdominal findings.

5. The patient is reporting an inability to clear nasal passages. Which action will the nurse take?

• A. Use gentle suction to prevent tissue damage.
• B. Instruct the patient to blow their nose forcefully to clear the passage.
• C. Place a dry washcloth under the nose to absorb secretions.
• D. Insert a cotton-tipped applicator into the back of the nose.

Correct answer: A

Rationale: When a patient reports an inability to clear nasal passages, the appropriate action for the nurse to take is to use gentle suction to prevent tissue damage. Suctioning helps remove excess mucus or secretions without causing harm to the nasal tissues. Instructing the patient to blow their nose forcefully (Choice B) may exacerbate the issue and cause discomfort or injury. Placing a dry washcloth under the nose (Choice C) is not an effective intervention for clearing nasal passages. Inserting a cotton-tipped applicator into the back of the nose (Choice D) is not recommended as it can be invasive and may cause injury or discomfort to the patient.

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