Nursing Elites

1. A healthcare professional is admitting a client who has decreased circulation in his left leg. Which of the following actions should the healthcare professional take first?

• A. Evaluate pedal pulses
• B. Assess skin temperature
• C. Check for capillary refill
• D. Measure the leg circumference

Correct answer: A

Rationale: Evaluating pedal pulses should be the first action taken as it provides immediate information about circulation. This assessment helps in determining the adequacy of blood flow in the client's leg. Assessing skin temperature, checking for capillary refill, and measuring leg circumference are important assessments; however, evaluating pedal pulses is the most crucial initial step in this scenario. Skin temperature assessment and capillary refill check can provide additional valuable information about perfusion, while measuring leg circumference is useful in monitoring for edema. Therefore, for a client with decreased circulation in the left leg, evaluating pedal pulses takes precedence over the other assessments.

2. During a neurological assessment, a healthcare provider is evaluating a client's balance. Which of the following examinations should the provider use for this purpose?

• A. Romberg test
• B. Deep tendon reflexes
• C. Mini-Mental State Examination
• D. Babinski reflex

Correct answer: A

Rationale: The Romberg test is utilized to assess the client's balance and proprioception by having them stand with their eyes closed. This test helps evaluate sensory ataxia, a condition where an individual's balance is affected due to impaired sensory input. Deep tendon reflexes (Choice B) are assessed by tapping a tendon with a reflex hammer to evaluate the integrity of the spinal cord and peripheral nerves; this is not directly related to balance assessment. The Mini-Mental State Examination (Choice C) is a cognitive screening tool used to assess cognitive impairment or dementia, not balance. The Babinski reflex (Choice D) is elicited by stroking the sole of the foot to assess neurologic function, particularly in the corticospinal tract, and is not specific to balance evaluation.

3. The healthcare professional is preparing to administer an intramuscular injection to an adult client. Which site is most appropriate for the LPN/LVN to use?

• A. Deltoid muscle
• B. Ventrogluteal site
• C. Dorsogluteal site
• D. Rectus femoris site

Correct answer: B

Rationale: The ventrogluteal site is the most appropriate and safest site for administering an intramuscular injection to an adult client. It is preferred due to its thick muscle mass and fewer major blood vessels and nerves in the area, reducing the risk of injury or complications. The deltoid muscle is commonly used for vaccines and small-volume injections but may not be suitable for larger volumes. The dorsogluteal site has fallen out of favor due to the risk of injury to the sciatic nerve and other underlying structures. The rectus femoris site is not typically used for intramuscular injections in adults.

4. A healthcare professional is preparing to administer medications to a client. Which of the following client identifiers should the healthcare professional use to ensure medication safety?

• A. Ask the client to state their full name.
• B. Ask the client for their date of birth.
• C. Compare the client's wristband with the medication administration record.
• D. Ask the client for their room number.

Correct answer: C

Rationale: Comparing the client's wristband with the medication administration record is a crucial step in ensuring medication safety. The wristband typically contains unique identifiers such as the client's name, date of birth, and medical record number, which should be cross-checked with the medication administration record to confirm the correct patient. Asking the client to state their name (Choice A) or date of birth (Choice B) may not be as reliable as the information can be misunderstood or miscommunicated. Asking for the room number (Choice D) is not a reliable client identifier for medication administration and does not confirm the patient's identity accurately.

5. While being educated by a nurse, an assistive personnel (AP) is learning about proper hand hygiene. Which statement made by the AP indicates a good understanding of the teaching?

• A. There are times I should use soap and water rather than alcohol-based hand rub to clean my hands.
• B. I can use alcohol-based hand rub after using the restroom.
• C. Soap and water are only necessary if my hands are visibly dirty.
• D. Hand rub is always sufficient, regardless of the situation.

Correct answer: C

Rationale: Choice C is the correct answer because it demonstrates an understanding that soap and water should be used when hands are visibly dirty or when dealing with specific pathogens. Choice A is incorrect because it suggests the use of soap and water over alcohol-based hand rub without specifying the circumstances. Choice B is incorrect as it implies that using alcohol-based hand rub after using the restroom is always suitable. Choice D is incorrect because it states that hand rub is always enough, which is not true when hands are visibly soiled or when specific pathogens are present.

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