Nursing Elites

1. A healthcare professional is instructing an AP about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client?

• A. Avoid measuring the client’s temperature rectally.
• B. Count the client’s radial pulse for 30 seconds and multiply it by 2.
• C. Count the client’s respirations discreetly.
• D. Allow the client to rest for 5 minutes before measuring their BP.

Correct answer: A

Rationale: The correct answer is to avoid measuring the client’s temperature rectally. Rectal temperatures can cause bleeding in clients with low platelet counts. It is crucial to avoid invasive methods that could increase the risk of bleeding or discomfort. Choice B, counting the radial pulse, is not directly related to the risk of bleeding in a client with low platelet count. Choice C, counting respirations discreetly, is important for accuracy but is not the priority when considering the risk of bleeding. Choice D, letting the client rest before measuring blood pressure, is beneficial but is not the priority in preventing potential harm due to low platelet counts.

2. The LPN is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer's disease. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen, the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication?

• A. Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care.
• B. Develop a chart for the client, listing the times the medication should be taken.
• C. Contact the primary health care provider and discuss the possibility of simplifying the medication regimen.
• D. Instruct the client and client's children to put medications in a weekly pill organizer.

Correct answer: C

Rationale: The priority nursing intervention in this scenario is to contact the primary health care provider and discuss the possibility of simplifying the medication regimen. Simplifying the medication regimen is crucial for a client with early Alzheimer's disease to ensure they can manage their medications independently and safely. This intervention focuses on optimizing the client's ability to adhere to the prescribed medication schedule. Choices A and D involve external assistance and may not address the core issue of simplifying the regimen. Choice B, while helpful, does not directly address the need to simplify the regimen to enhance the client's medication management.

3. An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take?

• A. Examine the elbow
• B. Administer pain medication
• C. Apply a warm compress to the elbow
• D. Assess the client’s range of motion

Correct answer: A

Rationale: The appropriate initial action for the nurse is to examine the elbow. This step is crucial to assess the site of pain, identify any visible signs of injury or inflammation, and determine the cause of the discomfort. Administering pain medication (Choice B) should come after a thorough assessment. Applying a warm compress (Choice C) might provide temporary relief but does not address the underlying cause. Assessing the client’s range of motion (Choice D) is important but would come after the initial examination to further evaluate the elbow joint.

4. A client with chronic kidney disease is experiencing hyperkalemia. Which medication should the LPN/LVN anticipate being prescribed to lower the client's potassium level?

• A. Furosemide (Lasix)
• B. Sodium polystyrene sulfonate (Kayexalate)
• C. Calcium gluconate
• D. Albuterol (Proventil)

Correct answer: B

Rationale: The correct answer is B: Sodium polystyrene sulfonate (Kayexalate). Kayexalate is commonly used to lower potassium levels in clients with hyperkalemia by exchanging sodium ions for potassium ions in the large intestine, leading to the elimination of excess potassium from the body. Choice A, Furosemide (Lasix), is a loop diuretic that helps with fluid retention but does not directly lower potassium levels. Choice C, Calcium gluconate, is used to treat calcium deficiencies and does not impact potassium levels. Choice D, Albuterol (Proventil), is a bronchodilator used to treat respiratory conditions and does not affect potassium levels. Therefore, the LPN/LVN should anticipate the prescription of Kayexalate to address the client's hyperkalemia.

5. Which statement by the mother indicates that the mother understands safety precautions with her four-month-old infant and her 4-year-old child?

• A. I secure the infant car seat in the back seat facing backwards.
• B. I place my infant in the middle of the living room floor on a blanket to play with my 4-year-old while I make supper in the kitchen.
• C. My sleeping baby looks adorable in the crib with the little buttocks up in the air while the four-year-old naps on the sofa.
• D. I have the 4-year-old hold and help feed the four-month-old a bottle in the kitchen while I make supper.

Correct answer: D

Rationale: Choice D is the correct answer because having the 4-year-old help feed the four-month-old a bottle in the kitchen while the mother makes supper shows supervision of the infant by the older child in a safe environment. This choice indicates that the mother understands safety precautions by involving the older child in a caregiving task under her supervision. Choices A, B, and C are incorrect because they involve unsafe practices such as placing the infant on the floor unsupervised, positioning the infant car seat in the front seat, and not providing direct supervision of the children during naptimes.

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