Nursing Elites

1. A client is receiving teaching from a healthcare provider about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will perform ankle and knee exercises every hour - Range of motion (ROM) is needed to prevent contractures.
• B. I will hold my breath when rising from a sitting position.
• C. I will remove my antiembolic stockings while I am in bed.
• D. I will have my partner help me change positions every 4 hours.

Correct answer: A

Rationale: Choice A is correct because performing ankle and knee exercises every hour helps prevent contractures and other adverse effects of immobility. Contractures are a common complication of immobility, and range of motion (ROM) exercises can help maintain joint flexibility and prevent contractures. This statement indicates an understanding of the teaching provided by the healthcare provider. Choices B, C, and D are incorrect. Holding the breath when rising from a sitting position can increase the risk of orthostatic hypotension, not reduce adverse effects of immobility. Removing antiembolic stockings while in bed can compromise their effectiveness in preventing deep vein thrombosis (DVT), which is not a measure to reduce immobility-related complications. Having a partner help change positions every 4 hours may not be frequent enough to prevent immobility-related complications effectively; changing positions more frequently is usually recommended to prevent issues like pressure ulcers and muscle stiffness.

2. A client with chronic kidney disease is being assessed. Which of the following laboratory values would be most concerning?

• A. Serum creatinine of 3.0 mg/dL
• B. Serum potassium of 6.5 mEq/L
• C. Blood urea nitrogen (BUN) of 45 mg/dL
• D. Hemoglobin of 10 g/dL

Correct answer: B

Rationale: In a client with chronic kidney disease, elevated serum potassium levels (hyperkalemia) are the most concerning finding. Hyperkalemia can lead to life-threatening cardiac dysrhythmias. Monitoring and managing serum potassium levels are crucial in patients with kidney disease to prevent severe complications. While elevated creatinine (Choice A) and BUN (Choice C) are indicative of impaired kidney function, hyperkalemia poses a more immediate threat to the client's health. Hemoglobin levels (Choice D) can be affected by chronic kidney disease but are not as acutely dangerous as severe hyperkalemia.

3. During the check-up of a 2-month-old infant at a well-baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?

• A. Mongolian spots are a normal finding in dark-skinned infants.
• B. Port wine stains are typically associated with other malformations.
• C. Telangiectatic nevi are normal and will disappear as the baby grows.
• D. The child is too young for surgical removal of these at this time.

Correct answer: C

Rationale: The correct answer is C. Telangiectatic nevi, often referred to as 'stork bites,' are common birthmarks in infants and are considered normal. These birthmarks usually fade and disappear as the child grows older. Choices A, B, and D are incorrect because Mongolian spots are bluish-gray birthmarks commonly found in darker-skinned infants, port wine stains are vascular birthmarks that typically do not disappear, and surgical removal is not recommended for telangiectatic nevi as they usually resolve on their own.

4. During an initial history and physical assessment of a 3-month-old brought into the clinic for spitting up and excessive gas, what would the nurse expect to find?

• A. Increased temperature and lethargy
• B. Restlessness and increased mucus production
• C. Increased sleeping and listlessness
• D. Diarrhea and poor skin turgor

Correct answer: B

Rationale: Restlessness and increased mucus production are common signs of gastrointestinal issues or reflux in infants, which could explain the symptoms of spitting up and excessive gas. Increased temperature and lethargy (Choice A) are more indicative of an infection rather than gastrointestinal issues. Increased sleeping and listlessness (Choice C) are not typical signs associated with the symptoms described. Diarrhea and poor skin turgor (Choice D) are not directly related to the symptoms of spitting up and gas in this scenario.

5. A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the LPN/LVN implement?

• A. Give an around-the-clock schedule for administration of analgesics.
• B. Administer analgesic medication as needed when the pain is severe.
• C. Provide medication to keep the client sedated and unaware of stimuli.
• D. Offer a medication-free period to allow the client to engage in daily activities.

Correct answer: A

Rationale: The correct action for the LPN/LVN to implement is to give an around-the-clock schedule for administration of analgesics. This approach helps maintain consistent pain management by providing the medication regularly, preventing the pain from becoming severe. Choice B is incorrect because waiting for severe pain before administering the analgesic may lead to uncontrolled pain levels. Choice C is inappropriate as the goal of pain management in hospice care is to provide comfort without unnecessary sedation. Choice D is also incorrect as offering a medication-free period may result in inadequate pain control for the client.

Similar Questions