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. The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the LPN/LVN administer?

• A. 1 ml.
• B. 1.5 ml.
• C. 1.75 ml.
• D. 2 ml.

Correct answer: B

Rationale: To calculate the correct dose of 15 mg, the LPN/LVN should administer 1.5 ml of Lasix (20 mg/2 ml). This calculation ensures precise dosing. Choice A (1 ml) is too low and would provide only 10 mg, while choice C (1.75 ml) and choice D (2 ml) would exceed the prescribed dose, resulting in potential adverse effects. It is important for the LPN/LVN to administer the exact prescribed dose to ensure therapeutic efficacy and avoid unnecessary complications.

3. When caring for an older adult client who becomes agitated when asked to remove dentures before surgery, which of the following responses should the nurse make?

• A. "What worries you about being without your teeth?"
• B. "You need to follow the preoperative instructions and remove your dentures."
• C. "It's important to remove dentures to ensure proper fitting of the mask during anesthesia."
• D. "I will explain why dentures need to be removed before surgery."

Correct answer: A

Rationale: The correct response is to ask the client about their concerns regarding being without their teeth. This approach helps address the client's anxiety and provides insight into the reason for their agitation. Choice B is authoritarian and does not address the client's emotional needs. Choice C focuses on the technical aspect of surgery and does not address the client's emotional state. Choice D implies a one-way communication without addressing the client's feelings or concerns.

4. A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further?

• A. “I am struggling to accept that my parents are aging and need so much help.”
• B. “It’s been so stressful for me to think about having intimate relationships.”
• C. “I know I should volunteer my time for a good cause, but maybe I’m just selfish.”
• D. “I love my grandchildren, but my child expects me to relive my parenting days.”

Correct answer: A

Rationale: The correct answer is A. The statement about struggling with aging parents indicates a significant stressor that could impact overall well-being and warrants further assessment. This statement reveals a potential source of emotional distress and adjustment difficulties for the client, as aging parents needing help can be a complex issue involving feelings of loss, role reversal, and increased responsibilities. Choices B, C, and D, although important, do not signify as immediate a need for further assessment compared to the challenges related to aging parents. Choice B focuses on intimate relationships, which is a common concern but may not be as urgent as dealing with aging parents. Choice C reflects feelings of selfishness but does not indicate an immediate need for further assessment. Choice D involves expectations from the client's child but does not highlight a critical issue that could impact the client's well-being as directly as struggling with aging parents.

5. A client has been on bed rest for several weeks. Which finding should the nurse identify as the priority during assessment?

• A. Musculoskeletal weakness
• B. Loss of appetite
• C. Increased heart rate during physical activity
• D. Left lower extremity tenderness

Correct answer: D

Rationale: The nurse should prioritize assessing left lower extremity tenderness as it could indicate deep vein thrombosis, a serious condition that requires immediate attention. Musculoskeletal weakness, loss of appetite, and increased heart rate during physical activity are important but not as critical as a potential thrombotic event that could lead to life-threatening complications. Deep vein thrombosis is a common risk for individuals on prolonged bed rest due to reduced mobility and blood stasis.

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