Nursing Elites

1. A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients?

• A. Members of the same religion may have varying feelings about their religion.
• B. A shared religion background does not guarantee identical beliefs.
• C. The same religious beliefs can influence individuals differently.
• D. Discussing differences and commonalities in beliefs may not always be relevant.

Correct answer: C

Rationale: The correct answer is C. Religious beliefs can vary widely even among individuals of the same faith. It is essential for the nurse to recognize that the impact and interpretation of religious beliefs can differ from person to person. Choice A is incorrect as individuals within the same religion can have diverse feelings and interpretations. Choice B is incorrect because a shared religious background does not necessarily mean that individuals hold the same beliefs. Choice D is not the best course of action as discussing differences and commonalities in beliefs may not always be necessary or appropriate for providing care.

2. What is the most important action for the LPN/LVN to take to prevent infection in a client with an indwelling urinary catheter?

• A. Ensure the catheter tubing is free of kinks.
• B. Change the catheter every 72 hours.
• C. Clean the perineal area with an antiseptic solution daily.
• D. Irrigate the catheter with normal saline every shift.

Correct answer: A

Rationale: The most crucial action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. This step helps prevent obstruction in the tubing, maintaining proper urine flow and reducing the risk of infection. Changing the catheter every 72 hours is not recommended unless clinically indicated, as routine changes can increase the risk of introducing pathogens. Cleaning the perineal area with an antiseptic solution is essential for general hygiene but does not directly prevent catheter-related infections. Irrigating the catheter with normal saline every shift is not a standard practice and can introduce microorganisms into the urinary tract, increasing the risk of infection.

3. During assessment, what is an indication of thrombophlebitis in a client who has been on bed rest for the past month?

• A. Calf swelling
• B. Elevated blood pressure
• C. Decreased urine output
• D. Generalized rash

Correct answer: A

Rationale: Calf swelling is a common sign of thrombophlebitis, which is inflammation of a vein due to a blood clot. Prolonged immobility can predispose individuals to thrombophlebitis. Calf swelling occurs due to the obstruction of blood flow, causing localized edema. This condition can lead to serious complications like pulmonary embolism if not promptly addressed. Elevated blood pressure, decreased urine output, and a generalized rash are not typically associated with thrombophlebitis. Elevated blood pressure may be linked to other conditions like hypertension, decreased urine output to kidney dysfunction, and a generalized rash to allergic reactions or skin conditions. Therefore, in a client on bed rest, calf swelling should raise suspicion of thrombophlebitis and prompt further evaluation and intervention.

4. While caring for a client who begins to experience a generalized seizure while standing in her room, which of the following actions should the nurse take?

• A. Place a pad under the client’s head
• B. Hold the client’s limbs tightly to prevent injury
• C. Lift the client into bed with the help of other staff members
• D. Insert a bite block into the client’s mouth

Correct answer: A

Rationale: During a seizure, the priority is to protect the client's head and ensure their safety. The nurse should guide the client to the ground if possible and place a soft pad or a folded cloth under the head to prevent injury. Restraining the client's limbs can result in injury and should be avoided. Lifting the client can also lead to injuries during a seizure. Inserting a bite block is contraindicated as it can cause damage to the teeth, oral tissues, and obstruct the airway. Therefore, the correct action is to place a pad under the client's head to protect them during the seizure.

5. During an admission history assessment, a client informs the nurse about consuming herbal tea every afternoon at work to alleviate stress. What ingredient is likely present in the tea?

• A. Chamomile
• B. Ginseng
• C. Ginger
• D. Echinacea

Correct answer: A

Rationale: The correct answer is A: Chamomile. Chamomile tea is commonly used for stress relief. Choice B, Ginseng, is not typically used in teas for stress relief but for energy and immune system support. Choice C, Ginger, is more commonly used for digestive health and nausea. Choice D, Echinacea, is often used to boost the immune system. Therefore, in the context of stress relief, Chamomile is the most appropriate ingredient.

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