Nursing Elites

1. When providing oral care for an unconscious client, which of the following actions should the nurse take?

• A. Place the client in a lateral position with the head turned to the side before beginning the procedure.
• B. Insert a suction catheter before brushing the teeth.
• C. Use a soft-bristled toothbrush only with water.
• D. Brush the client's teeth while they are in a supine position.

Correct answer: A

Rationale: When providing oral care for an unconscious client, it is essential to place them in a lateral position with the head turned to the side before beginning the procedure. This positioning helps prevent aspiration by allowing fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Inserting a suction catheter before brushing the teeth (Choice B) is not recommended as it can cause discomfort and increase the risk of oral tissue injury. Using a soft-bristled toothbrush only with water (Choice C) is not sufficient for effective oral care as toothpaste helps in removing plaque and bacteria. Brushing the client's teeth while they are in a supine position (Choice D) is not safe as it increases the risk of aspiration since fluids can easily enter the airway in this position.

2. An unlicensed assistive personnel (UAP) places a client in a left lateral position before administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP?

• A. Position the client on the right side of the bed in reverse Trendelenburg.
• B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
• C. Reposition the client in a Sim's position with the weight on the anterior ilium.
• D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Correct answer: C

Rationale: The correct instruction the LPN/LVN should provide to the UAP is to reposition the client in a Sim's position with the weight on the anterior ilium for administering a soap suds enema. This position helps facilitate the administration of the enema by providing better access and comfort for the client. Choice A is incorrect as reverse Trendelenburg is not the appropriate position for administering a soap suds enema. Choice B is incorrect as the concentration of soap in the enema solution is not specified and might be too strong. Choice D is incorrect as raising the side rails and elevating the bed does not directly relate to the proper positioning for administering the enema.

3. When applying an ice bag to a client's ankle following a sports injury, which of the following actions should the nurse take?

• A. Fill the bag two-thirds full with ice.
• B. Apply the ice bag directly to the skin with a barrier.
• C. Keep the ice bag on for more than 30 minutes at a time.
• D. Use a frozen gel pack instead of ice.

Correct answer: A

Rationale: Filling the ice bag two-thirds full is the correct action as it ensures the effectiveness of the ice application while allowing some space for the ice to move and conform to the injury. Choice B is incorrect because the ice bag should be applied with a barrier like a cloth to prevent direct contact with the skin, which can lead to ice burns. Choice C is wrong as ice should typically be applied for 20 minutes at a time to avoid tissue damage. Choice D is also incorrect as ice is preferred over frozen gel packs for immediate sports injury management.

4. A 16-year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?

• A. Ask the teenager to wait until a parent or legal guardian can be contacted
• B. Withhold treatment until telephone consent can be obtained from the partner
• C. Refer the teenager to a community pediatric hospital emergency department
• D. Proceed with the triage process in the same manner as any adult client

Correct answer: D

Rationale: The correct answer is to proceed with the triage process in the same manner as any adult client. In this scenario, since the teenager is legally married, they have the legal authority to consent to their own treatment. Choice A is incorrect because the teenager, being legally married, can provide their own consent. Choice B is incorrect as it unnecessarily delays treatment by waiting for telephone consent from the partner, which is not required in this case. Choice C is incorrect as the teenager can receive appropriate care in the current emergency department setting without the need for referral.

5. During assessment, what is a nurse monitoring when assessing body alignment?

• A. The relationship of one body part to another in different positions
• B. The coordination between musculoskeletal and nervous systems
• C. The force opposing movement direction
• D. The ability to move freely

Correct answer: A

Rationale: When a nurse assesses body alignment, they are observing the relationship of one body part to another in various positions. This involves evaluating the positioning of joints, tendons, ligaments, and muscles while a person is standing, sitting, or lying down. Choice B is incorrect because it refers more to the coordination between the musculoskeletal and nervous systems, which is not specifically related to body alignment assessment. Choice C is incorrect as it describes the force opposing movement rather than body alignment. Choice D is incorrect as it defines the ability to move freely, which is not directly related to monitoring body alignment.

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