Nursing Elites

1. When providing a bath, in which order will the nurse clean the body, beginning with the first area?

• A. Face
• B. Eyes
• C. Perineum
• D. Back and buttocks

Correct answer: B

Rationale: The correct sequence for giving a bath starts with cleaning the eyes, followed by the face, both arms, chest, hands/nails, abdomen, both legs, perineal hygiene, back, and finally the buttocks/anus. Therefore, the first area to be cleaned during a bath is the eyes. Choices A, C, and D are incorrect as per the standard procedure for providing a bath.

2. The client is receiving total parenteral nutrition (TPN). Which laboratory value should the LPN/LVN monitor closely to assess for complications?

• A. Serum potassium
• B. Blood glucose
• C. Serum sodium
• D. Serum calcium

Correct answer: B

Rationale: The correct answer is B: Blood glucose. When caring for a client receiving total parenteral nutrition (TPN), monitoring blood glucose levels is essential due to the risk of hyperglycemia. TPN solutions are high in glucose, and clients may be at risk of developing hyperglycemia if the infusion rate is too high or if there are underlying issues such as insulin resistance. Monitoring serum potassium (choice A) is important but not the most crucial value to monitor in clients receiving TPN. Serum sodium (choice C) and serum calcium (choice D) are not directly impacted by TPN administration and are less likely to be affected compared to blood glucose levels.

3. At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, where should the nurse place the stethoscope?

• A. Second intercostal space to the right of the sternum
• B. Fifth intercostal space to the left of the sternum
• C. Third intercostal space to the left of the sternum
• D. Fourth intercostal space at the midclavicular line

Correct answer: A

Rationale: The correct location to auscultate the aortic valve is the second intercostal space to the right of the sternum. This area corresponds to the aortic valve area where aortic valve sounds are best heard. Choices B, C, and D are incorrect for auscultating the aortic valve. The fifth intercostal space to the left of the sternum is where the mitral valve is best heard, the third intercostal space to the left of the sternum is where the pulmonic valve is best heard, and the fourth intercostal space at the midclavicular line is where the tricuspid valve is best auscultated.

4. A healthcare professional is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the healthcare professional use to obtain the temperature?

• A. Temporal
• B. Oral
• C. Rectal
• D. Axillary

Correct answer: C

Rationale: In a 2-year-old child with diarrhea and a possible ear infection, rectal temperature measurement is the most accurate reflection of core body temperature. This method provides the most reliable reading, especially in young children, as it closely reflects the core body temperature. Oral temperature may not be accurate due to the child's recent diarrhea, which can affect oral readings. Axillary temperature may not be as accurate as rectal temperature in this case. Temporal temperature measurement, although non-invasive, may not provide the most accurate core body temperature reading, especially in a child with a potential ear infection.

5. A healthcare professional reviewing a client’s health record notes a new prescription for lisinopril 10 mg PO once daily. The healthcare professional should identify this as which of the following types of prescription?

• A. Single
• B. Stat
• C. Routine
• D. Now

Correct answer: C

Rationale: A prescription for once-daily medication is considered routine as it is meant for regular, daily administration to maintain therapeutic levels in the body. Single prescriptions are for one-time use only. Stat prescriptions are for immediate administration in urgent situations, while now prescriptions are also for immediate use but may have varying levels of urgency depending on the patient's condition. In this case, since the prescription is for once daily use, it falls under the category of routine prescription.

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