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 young mother of three children complains of increased anxiety during her annual physical exam. What information should the LPN/LVN obtain first?

• A. Sexual activity patterns.
• B. Nutritional history.
• C. Leisure activities.
• D. Financial stressors.

Correct answer: B

Rationale: The LPN/LVN should first obtain the nutritional history in this scenario. Nutrition plays a crucial role in mental health, and deficiencies or imbalances in diet can contribute to anxiety symptoms. Understanding the mother's nutritional intake can help identify any factors exacerbating her anxiety. Sexual activity patterns are not directly relevant to her anxiety symptoms unless specifically indicated. Leisure activities and financial stressors may be important but are secondary to addressing the potential impact of nutrition on anxiety.

3. 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.

4. The healthcare provider is teaching a patient about contact lens care. Which instructions will the healthcare provider include in the teaching session?

• A. Use tap water to clean soft lenses.
• B. Wash and rinse the lens storage case daily.
• C. Reuse storage solution for no longer than a week.
• D. Keep the lenses in a cool, dry place when not in use.

Correct answer: B

Rationale: The correct answer is B. Washing and rinsing the lens storage case daily is essential to prevent contamination and infections. Choice A is incorrect as tap water should not be used to clean soft lenses due to the risk of introducing harmful microorganisms. Choice C is incorrect as the storage solution should not be reused for longer than recommended to maintain its effectiveness and prevent eye infections. Choice D is incorrect because lenses should be stored in a clean, disinfected case, not just in a cool, dry place, to avoid contamination.

5. The female is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient?

• A. Should be postponed because it may cause embarrassment.
• B. Should be unnecessary because the patient is uncircumcised.
• C. Should be done by the patient.
• D. Should be done by the nurse.

Correct answer: C

Rationale: Perineal care should be encouraged to be done by the patient if they are capable of performing self-care. In this scenario, the patient is not ambulatory and has full function of all extremities, indicating that the patient can independently perform perineal care. Encouraging self-care promotes independence and maintains the patient's dignity. Postponing perineal care (Choice A) is incorrect because it is essential for hygiene. Choice B is incorrect as perineal care is necessary for all patients regardless of circumcision status. Choice D is incorrect as the patient is capable of performing the care independently, and promoting self-care is a priority in nursing practice.

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