Nursing Elites

1. A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

• A. A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.
• B. The nurse avoids discussing the client's diagnosis to prevent emotional distress.
• C. The nurse provides a vague answer about the client's condition.
• D. The nurse promises to provide information only if it is requested by the client.

Correct answer: A

Rationale: Veracity involves telling the truth, a fundamental ethical principle in healthcare. In this scenario, the nurse demonstrates veracity by responding honestly when the client directly asks about her cancer diagnosis. Choice B is incorrect as avoiding discussing the diagnosis to prevent emotional distress does not align with veracity and transparency. Choice C is incorrect as providing a vague answer does not uphold the principle of truthfulness. Choice D is incorrect because promising to provide information only upon client request does not address the immediate question about the cancer diagnosis and lacks transparency.

2. Which anatomical location is associated with the deep tendon reflex known as the patellar reflex?

• A. Knee picture
• B. Ankle picture
• C. Elbow picture
• D. Wrist picture

Correct answer: A

Rationale: The patellar reflex, also called the knee-jerk reflex, is elicited by tapping the patellar tendon just below the patella. This reflex involves the quadriceps muscle and the femoral nerve. The correct answer is 'A: Knee picture' because the patellar reflex is associated with the knee joint. Choices B, C, and D are incorrect as they do not correspond to the anatomical location involved in the patellar reflex.

3. A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding 'stronger pain medications.' What initial action is most important for the LPN/LVN to take?

• A. Ask about any past history of drug abuse or addiction.
• B. Measure the pulse volume and capillary refill distal to the infiltration.
• C. Compress the infiltrated tissue to measure the degree of edema.
• D. Evaluate the extent of ecchymosis over the forearm area.

Correct answer: B

Rationale: The most important initial action for the LPN/LVN to take in this situation is to measure the pulse volume and capillary refill distal to the infiltration. This assessment helps evaluate the severity of the infiltration and the circulation in the affected arm. Asking about past history of drug abuse or addiction (Choice A) is not the priority when addressing acute arm pain and infiltration. Compressing the infiltrated tissue (Choice C) may exacerbate the pain and is not recommended as the first step. Evaluating the extent of ecchymosis (Choice D) is not as critical as assessing the circulation in the affected arm, which is better addressed by measuring pulse volume and capillary refill.

4. The nurse is caring for a client who is post-operative following a cholecystectomy. Which assessment finding would require immediate intervention?

• A. Absent bowel sounds
• B. Pain level of 8/10
• C. Temperature of 100.4°F
• D. Saturated abdominal dressing

Correct answer: D

Rationale: A saturated abdominal dressing may indicate active bleeding or other complications that require immediate intervention, such as ensuring hemostasis and preventing further complications. Absent bowel sounds are common in the immediate post-operative period and may not require immediate intervention unless accompanied by other symptoms. A pain level of 8/10 can be managed with appropriate pain medication and is not typically considered an immediate priority unless other indications suggest complications. A temperature of 100.4°F is slightly elevated but may not be a cause for immediate concern unless it is associated with other signs of infection or distress that would warrant urgent attention.

5. The healthcare professional caring for a patient who is immobile frequently checks for impaired skin integrity. What is the rationale for this action?

• A. Inadequate blood flow leads to decreased tissue ischemia.
• B. Patients with limited caloric intake develop thicker skin.
• C. Pressure reduces circulation to affected tissue.
• D. Verbalization of skin care needs is decreased.

Correct answer: C

Rationale: The rationale behind checking for impaired skin integrity in an immobile patient is that pressure reduces circulation to the affected tissue. Prolonged pressure on specific body parts can lead to reduced blood flow to those areas, causing tissue damage and potentially leading to pressure ulcers. Choices A, B, and D are incorrect because inadequate blood flow causing decreased tissue ischemia, limited caloric intake leading to thicker skin, and decreased verbalization of skin care needs are not directly related to the rationale for checking for impaired skin integrity in immobile patients.

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