Nursing Elites

1. A nurse is assisting with data collection regarding skin and peripheral vascular findings on a client in later adulthood. Which observation would the nurse expect to note as an age-related finding?

• A. Thin, ridged toenails
• B. Thick skin on the lower legs
• C. Loss of hair on the lower legs
• D. Bounding dorsalis pedis pulse

Correct answer: C

Rationale: In later adulthood, age-related findings include trophic changes associated with arterial insufficiency, such as thin, shiny skin; thin, ridged toenails; and loss of hair on the lower legs. These changes occur normally with aging. Thick skin on the lower legs would not be an expected age-related finding as it typically indicates chronic venous insufficiency. A bounding dorsalis pedis pulse is not typical in later adulthood and may indicate arterial insufficiency, which is not an age-related finding.

2. Which of the following actions should the LPN perform for a client with an active digoxin IV order? Select all that apply.

• A. plug the patient to the ECG Monitor
• B. Administer the medication over at least 5 minutes.
• C. Monitor respirations during administration.
• D. Monitor the client's pulse for 1 minute prior to administration.

Correct answer: D

Rationale: The correct actions for the LPN to perform for a client with an active digoxin IV order are to monitor ECG rhythm throughout administration and monitor the client's pulse for 1 minute prior to administration. These actions are crucial as digoxin affects the heart's electrical activity, and it should not be administered if the client's pulse is less than 60 bpm. Monitoring respirations and blood pressure are not directly associated with digoxin administration. Administering IV medications is typically outside the LPN's scope of practice.

3. The LPN is caring for a 9-month-old infant. Which of these behaviors exhibited by the child warrants further investigation?

• A. She prefers crawling over walking and makes no attempt to walk.
• B. She seems distressed by new adults.
• C. She does not respond to her own name.
• D. She only babbles "mama"? and "dada."?

Correct answer: C

Rationale: The correct answer is that the child does not respond to her own name. By 9 months, children should be babbling simple words, crawling, and responding to their name. Not responding to one's name can be an early indicator of a potential developmental delay, warranting further investigation. Preferring crawling over walking, being distressed by new adults, and babbling 'mama' and 'dada' are typical behaviors for a 9-month-old and do not necessarily require immediate concern.

4. The nurse has a client who is being transferred to another floor right around change of shift. Which of the following actions is least appropriate?

• A. Inform the staff on the other floor of any unresolved issues with the client.
• B. Ask the charge nurse if overtime would be permitted to complete the client's transfer to the other floor.
• C. Ask the new nurse to take care of the transfer since the client's medical record has all of the information, and a report should not be needed.
• D. Complete the transfer paperwork before the client is transferred.

Correct answer: C

Rationale: The least appropriate action in this scenario is to ask the new nurse to take care of the transfer without providing a full handoff of care. It is crucial to ensure a safe handoff during the transfer to maintain continuity of care and patient safety. Informing the staff on the other floor of any unresolved issues with the client (Choice A) is important for the client's well-being as it helps in providing comprehensive care. Asking the charge nurse about overtime (Choice B) demonstrates consideration for completing the task effectively, but it should not take precedence over ensuring a proper handoff. Completing the transfer paperwork before the client is transferred (Choice D) is necessary to ensure all documentation is in order, but it should be done in conjunction with providing a thorough handoff of care to the new nurse.

5. A nurse is explaining a nonstress test to a pregnant client. The nurse explains that the results are nonreactive if which finding is noted on the electronic monitoring recording strip?

• A. Two fetal heart accelerations within a 20-minute period, peaking at 15 beats/min above baseline and lasting 15 seconds from baseline to baseline
• B. Accelerations without fetal movement with fetal heart rate (FHR) increases of 15 beats/min for 15 seconds
• C. Acceleration of the FHR by 25 to 30 beats/min for at least 15 seconds in response to fetal movement
• D. Absence of accelerations after fetal movement

Correct answer: D

Rationale: The correct answer is 'Absence of accelerations after fetal movement.' In a nonreactive (nonreassuring) stress test, the monitor recording would not show accelerations after fetal movement within a 40-minute period. This absence of accelerations indicates a nonreactive result. Choices A, B, and C describe different patterns of fetal heart rate accelerations that are not indicative of a nonreactive result in a nonstress test, making them incorrect. Choice A describes the characteristics of a reactive (reassuring) result, where there should be at least two fetal heart accelerations within a 20-minute period, peaking at least 15 beats/min above the baseline, and lasting 15 seconds from baseline to baseline. Choice B incorrectly states 'Accelerations without fetal movement,' which is contradictory. Choice C describes an acceleration response to fetal movement, which does not signify a nonreactive result.

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