Nursing Elites

1. A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?

• A. Bag bath
• B. Sponge bath
• C. Partial bed bath
• D. Complete bed bath

Correct answer: C

Rationale: The correct answer is a partial bed bath (Choice C). A partial bed bath involves washing body parts that the patient cannot reach on their own, such as the back. It also includes providing assistance with a backrub to promote circulation and skin integrity. In this scenario, where the patient is bedridden and unable to reach all body parts, a partial bed bath is the most appropriate as it focuses on areas the patient cannot clean themselves. Choices A, B, and D are incorrect because a bag bath involves using premoistened disposable cloths for bathing, a sponge bath involves using a basin of water and a sponge for cleansing, and a complete bed bath involves washing the entire body, including areas the patient can reach, which are not necessary in this case.

2. A client is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action?

• A. Assess the client's perineum
• B. Administer pain medication
• C. Clean the area with a mild cleanser
• D. Apply a barrier cream to the affected area

Correct answer: A

Rationale: Assessing the client's perineum is the priority nursing action in this situation. By checking the perineum, the nurse can evaluate for skin damage, irritation, infection, or other issues that may be causing the client's pain. This assessment is crucial to determine the appropriate interventions needed to address the client's discomfort and prevent complications. Administering pain medication, cleaning the area with a mild cleanser, or applying a barrier cream are important interventions but should follow the initial assessment of the perineum to ensure comprehensive care and effective management of the client's condition. Prioritizing assessment allows for a targeted and individualized approach to care, enhancing the client's overall well-being.

3. The mother of a toddler calls the nurse for help as the baby is choking on his food. The nurse determines that the Heimlich maneuver is necessary based on which finding?

• A. Inability of the toddler to cry or speak
• B. Coughing forcefully
• C. Gagging but able to breathe
• D. Wheezing during respiration

Correct answer: A

Rationale: The correct answer is option A: Inability of the toddler to cry or speak. In cases of choking, the inability to cry or speak indicates a severe airway obstruction where the Heimlich maneuver is necessary to clear the obstruction and establish a patent airway. Option B, coughing forcefully, represents a partial obstruction where the child can still move air, making the Heimlich maneuver not immediately necessary. Option C, gagging but able to breathe, suggests a partial obstruction where air is moving, and the child can still breathe, not requiring immediate intervention like the Heimlich maneuver. Option D, wheezing during respiration, is more indicative of a lower airway issue such as asthma rather than an upper airway obstruction that necessitates the Heimlich maneuver.

4. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the LPN/LVN to implement?

• A. Contact the healthcare provider and complete a medication variance form.
• B. Administer the Levaquin at 1300 and resume the 0900 schedule the next morning.
• C. Notify the charge nurse and complete an incident report to explain the missed dose.
• D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

Correct answer: D

Rationale: The correct intervention is to give the missed dose at 1300 and adjust the schedule to administer daily at 1300. This approach ensures that the client receives the correct total daily dose of levofloxacin. Choice A is incorrect because contacting the healthcare provider and completing a medication variance form would not address the immediate need to administer the missed dose. Choice B is incorrect as administering the missed dose at 1300 and resuming the 0900 schedule the next morning would result in a missed dose for that day. Choice C is not the best course of action as notifying the charge nurse and completing an incident report should come after addressing the immediate need to administer the missed dose and adjusting the schedule for future doses.

5. When assessing a male client, the nurse finds that he is fatigued and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which condition?

• A. Hyperphosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hypokalemia

Correct answer: D

Rationale: The symptoms of muscle weakness, leg cramps, and cardiac dysrhythmias are indicative of hypokalemia, a condition characterized by low potassium levels. Checking the client's laboratory values for potassium will help confirm this diagnosis. Hyperphosphatemia (Choice A) is an elevated phosphate level in the blood, which is not consistent with the symptoms described. Hypocalcemia (Choice B) is a low calcium level and typically presents with different symptoms than those mentioned in the scenario. Hypermagnesemia (Choice C) is an excess of magnesium in the blood and does not align with the symptoms of muscle weakness, leg cramps, and cardiac dysrhythmias observed in the client.

Similar Questions