Nursing Elites

1. A nurse assisting with data collection plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal which disorder?

• A. Loss of hearing acuity
• B. A problem with balance
• C. A problem with distant hearing
• D. A problem discriminating high-pitched and low-pitched sounds

Correct answer: B

Rationale: The Romberg test is a balance assessment that evaluates cerebellar function. During the test, the client stands with feet together and eyes closed, aiming to maintain balance for about 20 seconds. This test helps identify issues related to balance and proprioception, not hearing acuity or sound discrimination. Choices C and D are incorrect as the Romberg test focuses on balance, not distant hearing or sound discrimination.

2. While taking the vital signs of a pregnant client admitted to the labor unit, a nurse notes a temperature of 100.6�F, pulse rate of 100 beats/min, and respirations of 24 breaths/min. What is the most appropriate nursing action based on these findings?

• A. Notify the registered nurse of the findings.
• B. Document the findings in the client's medical record.
• C. Recheck the vital signs in 1 hour.
• D. Continue collecting subjective and objective data.

Correct answer: A

Rationale: The correct answer is to notify the registered nurse of the findings. In a pregnant client, the normal temperature range is 98�F to 99.6�F, with a pulse rate of 60 to 90 beats/min and respirations of 12 to 20 breaths/min. A temperature of 100.4�F or higher, along with an increased pulse rate and faster respirations, suggests a possible infection. Immediate notification of the registered nurse is crucial for further evaluation and intervention. While documenting the findings is essential, the priority lies in promptly escalating abnormal vital signs for assessment and management. Rechecking vital signs in 1 hour may delay necessary interventions for a deteriorating condition. Continuing to collect data is relevant but should not delay informing the registered nurse when abnormal vital signs are present.

3. Regarding maternal and infant mortality and morbidity, a concern is that:

• A. a segment of the population is not receiving prenatal care.
• B. families may not prioritize quality health care.
• C. there might be an increase in the shortage of personnel in the maternity field.
• D. maternal-child health workers may lack adequate preparation.

Correct answer: A

Rationale: The correct answer is that a segment of the population is not receiving prenatal care. This is a significant concern as lack of access to prenatal care can lead to adverse outcomes for both the mother and the infant. Choice B is incorrect as it generalizes families as unconcerned, which may not be the case for all families. Choice C is also incorrect as there is no evidence or indication in the prompt to suggest an increase in the shortage of personnel. Choice D is not directly related to the concern mentioned in the prompt, which specifically focuses on the lack of prenatal care.

4. When a client wishes to improve her appearance by removing excess skin from her face and neck, the nurse should provide teaching regarding which of the following procedures?

• A. dermabrasion
• B. rhinoplasty
• C. blepharoplasty
• D. rhytidectomy

Correct answer: D

Rationale: The correct answer is 'rhytidectomy.' Rhytidectomy, commonly known as a face-lift, is the procedure for removing excess skin from the face and neck. Dermabrasion involves spraying a chemical to freeze the skin lightly, followed by abrasion with sandpaper or a revolving wire brush, used for removing scars, severe acne, and tattoo pigment. Rhinoplasty is for improving the nose's appearance by reshaping the nasal skeleton and overlying skin. Blepharoplasty removes loose and protruding fat from the upper and lower eyelids. Therefore, when a client wants to address excess skin in the face and neck, rhytidectomy is the appropriate procedure.

5. The LPN is taking care of a client with a documented allergy to Penicillin. After rounds, the LPN notices that the client has an order for Cefazolin. Which of the following actions would be the least appropriate?

• A. The LPN clarifies the severity of the Penicillin allergy.
• B. The LPN discusses the order with the care team prior to administering Cefazolin.
• C. The LPN administers all ordered medications except for the Cefazolin.
• D. The LPN monitors the client after a test dose of Cefazolin is administered.

Correct answer: C

Rationale: The least appropriate action is for the LPN to administer all ordered medications except for the Cefazolin. The LPN should always consider the client's documented allergy to Penicillin seriously. It is crucial to discuss the order with the care team before administering Cefazolin to ensure patient safety. Administering a medication that could potentially cause harm due to a documented allergy is unsafe practice. While monitoring the client after a test dose of Cefazolin is important, it should not precede clarification with the care team regarding the allergy and the appropriateness of the medication. Therefore, withholding the Cefazolin is the most appropriate action in this scenario.

Similar Questions