Nursing Elites

1. A group of newly licensed nurses is being taught about the Braden Scale by a nurse. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

• A. “The client’s age is not a factor in the measurement.”
• B. “The scale measures six elements.”
• C. “A lower score indicates a higher risk of pressure ulcers.”
• D. “Each element is scored on a range from 1 to 4 points.”

Correct answer: B

Rationale: Choice B is the correct answer because the Braden Scale measures six elements: Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction, and Shear. The other choices are incorrect because: Choice A states that the client's age is not a factor in the measurement, which is accurate as age is not included in the Braden Scale. Choice C incorrectly states that a lower score indicates a higher risk of pressure ulcers, which is the opposite of how the Braden Scale works. Choice D inaccurately describes the scoring range of each element on the Braden Scale, which is not from 1 to 4 points but rather from 1 to 3.

2. A client who is postoperative is being taught how to use a flow-oriented incentive spirometer. Which of the following instructions should be included by the nurse?

• A. Cough deeply after each use.
• B. Take a deep breath and hold for 10 seconds.
• C. Breathe in slowly and deeply to raise the ball or piston.
• D. Exhale forcefully before using the spirometer.

Correct answer: C

Rationale: The correct technique for using a flow-oriented incentive spirometer involves breathing in slowly and deeply to raise the ball or piston. This action helps to expand the lungs and improve lung function. Option A is incorrect as coughing deeply after each use is not part of using the spirometer. Option B is incorrect as holding the breath for 10 seconds is not the correct instruction for using the spirometer. Option D is incorrect as exhaling forcefully before using the spirometer is not the appropriate step in using this device.

3. A nurse is preparing change of shift report after the night shift using one SBAR communication tool. Which of the following data should the nurse include when reporting background information?

• A. “Blood pressure 160/92 mm Hg”
• B. “Start the first dose of penicillin at 1200”
• C. “Pain rating of 5 on a scale from 0 to 10”
• D. “Code status: do-not-resuscitate”

Correct answer: B

Rationale: The correct answer is B. When providing background information in a shift report using the SBAR communication tool, the nurse should include details related to medication administration and orders. This helps ensure continuity of care and accurate handover of responsibilities. Choices A, C, and D do not typically fall under background information for shift reports. A blood pressure reading, pain rating, and code status are more relevant to the patient's current condition and status, rather than background information about medications or orders.

4. A client with hypertension is prescribed a low-sodium diet. Which food should the LPN/LVN recommend the client avoid?

• A. Fresh fruits
• B. Grilled chicken
• C. Whole grain bread
• D. Canned soup

Correct answer: D

Rationale: The correct answer is D, canned soup. Canned soup is often high in sodium, which contradicts the low-sodium diet prescribed for hypertension. Fresh fruits (A) are generally low in sodium and are a healthy choice. Grilled chicken (B) is a lean protein option that is suitable for a low-sodium diet. Whole grain bread (C) is also a good choice as it is not typically high in sodium. Therefore, the LPN/LVN should recommend avoiding canned soup to adhere to the low-sodium dietary restrictions.

5. After a client's death in a long-term care facility, identify the correct sequence of steps for the nurse to perform.

• A. 1) Place a name tag on the body 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body
• B. 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body 1) Place a name tag on the body
• C.
• D.

Correct answer: B

Rationale: The correct sequence of steps for the nurse in a long-term care facility after a client's death is as follows: First, obtain the pronouncement of death from the provider. Second, remove tubes and indwelling lines before proceeding to wash the client's body. Third, ask the client's family members if they would like to view the body. Finally, place a name tag on the body. This order ensures that the necessary procedures are followed with respect and consideration for the deceased client and their family. Choice B is correct. Choices A, C, and D are incorrect as they do not follow the appropriate sequence of actions required in this situation.

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