Nursing Elites

1. 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.

2. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the LPN/LVN to take?

• A. Record the coughing incident. No further action is required at this time.
• B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
• C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
• D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

Correct answer: C

Rationale: After a client experiences severe coughing following nasogastric tube feedings, it is crucial to verify proper tube placement. Checking the pH of fluid withdrawn from the tube helps confirm the tube's correct positioning. Option A is incorrect because further action is necessary to ensure the client's safety. Option B is inappropriate as it suggests stopping the feeding without assessing the tube's placement. Option D is incorrect as injecting air into the tube may lead to further complications if the tube is not positioned correctly.

3. A nurse is caring for a client who has herpes zoster. The client asks about complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?

• A. Acupuncture
• B. Massage therapy
• C. Aromatherapy
• D. Herbal supplements

Correct answer: A

Rationale: The correct answer is A, Acupuncture. Acupuncture is contraindicated for clients with herpes zoster due to the risk of infection at the needle sites. In individuals with herpes zoster, the skin's integrity is compromised, increasing susceptibility to infections. Therefore, acupuncture, which involves inserting needles into the skin, can introduce pathogens and lead to local infections. Massage therapy (B), aromatherapy (C), and herbal supplements (D) do not involve skin penetration like acupuncture and are generally considered safe complementary therapies for pain control in clients with herpes zoster.

4. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

• A. The client's comfort level is increased when the nurse maintains eye contact while typing notes into the record
• B. The interview process is hindered by electronic documentation and may disrupt the flow of conversation
• C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
• D. Completing the electronic record during an interview is optional and not a legal obligation of the examining nurse

Correct answer: C

Rationale: The most accurate statement is that the nurse has a limited ability to observe nonverbal communication while entering the assessment electronically. This is because the nurse's focus is on typing or inputting data, which may lead to missing important nonverbal cues from the client. Choices A and B are incorrect as they do not address the limitation of observing nonverbal cues. Choice A is incorrect because breaking eye contact to type notes may hinder the client's comfort level. Choice B is incorrect because it states that electronic documentation enhances the interview process, which may not always be the case. Choice D is incorrect as completing the electronic record during an interview is typically a standard practice but not a legal obligation.

5. How can the LPN/LVN best handle the situation of a postoperative client being kept awake by a neighboring client with dementia who sings all night?

• A. Tell the neighboring client to stop singing.
• B. Close the doors to both clients' rooms at night.
• C. Give the complaining client the prescribed sedative as needed.
• D. Move the neighboring client to a room at the end of the hall.

Correct answer: D

Rationale: The best way to handle the situation in this scenario is to move the neighboring client to a room at the end of the hall. This solution is considerate to both clients because it addresses the issue by providing a quieter environment for the client with dementia while allowing the postoperative client to rest. Choice A is inappropriate as it does not address the root cause of the problem and may not be feasible or respectful. Choice B of closing the doors may not effectively reduce the noise disturbance. Choice C of giving the complaining client sedatives should be the last resort and not the initial solution, as it does not address the underlying issue causing the disturbance.

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