Nursing Elites

1. A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except:

• A. the client reports no episodes of awakening during the night.
• B. the client falls asleep within 1 hour of going to bed.
• C. the client reports satisfaction with their amount of sleep.
• D. the client rates sleep as an 8 or more on the visual analog scale.

Correct answer: B

Rationale: An expected outcome for a nursing care plan targeting sleep problems is that the client reports no episodes of awakening during the night, the client reports satisfaction with their amount of sleep, and the client rates sleep as an 8 or more on the visual analog scale. Falling asleep within 1 hour of going to bed is not necessarily an expected outcome. While it is generally desirable for individuals to fall asleep within a reasonable time frame, this specific timeframe may vary among individuals, and it is not a strict criterion for successful sleep outcomes. Therefore, the correct answer is that the client falls asleep within 1 hour of going to bed, as this is not a definitive measure of the effectiveness of the nursing care plan for sleep problems.

2. A licensed practical nurse (LPN) in the long-term care unit who has another LPN and a nursing assistant on the nursing team is planning task assignments for the day. Which task should the nurse assign to the LPN?

• A. Monitoring a client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments
• B. Assisting a client who is wearing eye patches and requires assistance with hygiene measures
• C. Feeding a client on bedrest who needs assistance with feeding
• D. Turning a client who must be turned and repositioned every 2 hours

Correct answer: A

Rationale: When a nurse assigns tasks for a client's care to another staff member, the nurse is responsible for appropriately assigning tasks based on the educational level and competency of the staff member. In this scenario, the LPN should be assigned the task of monitoring a client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments. This is because the LPN is competent to perform these tasks and can accurately note changes in the client's condition. Tasks such as feeding a client, turning and repositioning a client, and assisting with hygiene measures, which are noninvasive interventions, can be assigned to a nursing assistant. These tasks do not require the same level of assessment and monitoring as the respiratory treatments and pulse oximetry monitoring.

3. Following a recent tattoo, someone should be screened for:

• A. tuberculosis.
• B. herpes.
• C. hepatitis.
• D. syphilis.

Correct answer: C

Rationale: Following a recent tattoo, someone should be screened for hepatitis. Tattooing puts a client at risk for blood-borne hepatitis B or C if strict sterile procedures are not followed. Tuberculosis is an airborne pathogen, while herpes and syphilis are spread through direct contact like sexual activity. Therefore, hepatitis is the most relevant infection to screen for after getting a tattoo.

4. After receiving a recent tattoo, someone should be screened for:

• A. tuberculosis.
• B. herpes.
• C. hepatitis.
• D. syphilis.

Correct answer: C

Rationale: After receiving a recent tattoo, screening for hepatitis is crucial due to the risk of blood-borne hepatitis B or C if strict sterile procedures are not followed during the tattooing process. Tuberculosis is an airborne pathogen and is not directly related to receiving a tattoo. Herpes and syphilis are infections spread through direct contact, such as sexual contact, and are not typically associated with tattooing.

5. What should be the primary action for a client who has just vomited 300 cc of bright red blood?

• A. Document the vomiting.
• B. Increase IV fluids.
• C. Get a complete blood count.
• D. Check the blood pressure.

Correct answer: D

Rationale: The correct first action for a client who has just vomited 300 cc of bright red blood is to check the blood pressure. This assessment is crucial to evaluate for hypotension, which could indicate significant blood loss and the need for immediate intervention. Documenting the vomiting is important for the client's medical record but not the initial priority. Increasing IV fluids and getting a complete blood count are necessary steps but should follow the assessment of the client's hemodynamic status.

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