Nursing Elites

1. 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.

2. The client is preparing for discharge following treatment for heart failure. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself every day at the same time.
• B. I will call my doctor if my legs swell more.
• C. I will take my water pill only when I feel short of breath.
• D. I will limit the amount of salt in my diet.

Correct answer: C

Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to manage fluid retention. Option A is correct as daily weight monitoring helps track for fluid retention. Option B is correct as worsening leg swelling should prompt contacting the healthcare provider. Option D is correct as limiting salt intake is essential in managing heart failure. Therefore, option C is the statement that indicates a need for further teaching.

3. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the LPN have for planning care in terms of the client's beliefs?

• A. Autopsy of the body is prohibited.
• B. Blood transfusions are forbidden.
• C. Alcohol use in any form is not allowed.
• D. A vegetarian diet must be followed.

Correct answer: B

Rationale: The correct answer is B: 'Blood transfusions are forbidden.' Jehovah's Witnesses typically refuse blood transfusions due to their religious beliefs. This is crucial for the LPN to consider when planning the client's care to ensure that alternative treatments are explored. Choices A, C, and D are incorrect as they do not align with the specific beliefs and practices of Jehovah's Witnesses. Autopsy prohibition, alcohol use restrictions, and dietary preferences are not primary concerns related to the religious beliefs of Jehovah's Witnesses.

4. A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?

• A. A nurse tied a client's restraints straps to the moveable part of the bed frame.
• B. An assistive personnel placed a surgical mask on a client who has TB before transporting her to radiology.
• C. A nurse administered a medication to a client 30 minutes before the dose is due.
• D. A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

Correct answer: C

Rationale: The correct answer is C. An incident report should be completed when a nurse administers medication to a client significantly earlier than the scheduled time. This deviation from the prescribed schedule could potentially impact the client's treatment plan and requires documentation for proper evaluation and follow-up. Choices A, B, and D do not necessarily require an incident report. Choice A involves improper restraint application, which is a safety issue but does not directly involve medication administration. Choice B involves a protective measure for a client with TB, which is within the scope of practice for assistive personnel. Choice D describes an increase in IV fluid administration, which may need monitoring but does not necessarily indicate a need for an incident report unless there are specific complications or adverse effects related to the additional fluid.

5. The nurse is caring for an adult who has fluid volume excess. When weighing the client, the nurse should:

• A. Weigh the client upon rising
• B. Weigh the client at different times of the day
• C. Weigh the client after meals
• D. Weigh the client weekly

Correct answer: A

Rationale: Weighing the client upon rising is the correct approach when caring for a client with fluid volume excess. Weighing the client in the morning upon rising provides a consistent and accurate measure of weight, as it helps to eliminate the influence of daily fluctuations that can occur throughout the day. Weighing at different times of the day (choice B) may lead to inconsistent measurements due to variations in food intake, hydration status, and other factors. Weighing the client after meals (choice C) can also lead to inaccurate readings as food and fluid intake can affect weight. Weighing the client weekly (choice D) is not frequent enough to monitor changes in weight accurately for a client with fluid volume excess.

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