Nursing Elites

1. An assistive personnel says to the nurse, “This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her.” Which is the appropriate nursing response?

• A. You should report this to the supervisor
• B. It is very upsetting to see an adult client regress
• C. Diapers are the best solution
• D. The client’s condition is not your concern

Correct answer: B

Rationale: The correct response is 'It is very upsetting to see an adult client regress.' In this situation, the nurse should acknowledge the emotional impact of caregiving on the assistive personnel and address it professionally. Choice A is incorrect because reporting to the supervisor may not directly address the emotional concerns raised. Choice C is incorrect because immediately resorting to diapers without further assessment or intervention is not the most appropriate solution. Choice D is incorrect as the client's well-being and care are a shared responsibility among healthcare team members.

2. The client is preparing for discharge following treatment for heart failure. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself every day at the same time.
• B. I will call my doctor if my legs swell more.
• C. I will take my water pill only when I feel short of breath.
• D. I will limit the amount of salt in my diet.

Correct answer: C

Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to manage fluid retention. Option A is correct as daily weight monitoring helps track for fluid retention. Option B is correct as worsening leg swelling should prompt contacting the healthcare provider. Option D is correct as limiting salt intake is essential in managing heart failure. Therefore, option C is the statement that indicates a need for further teaching.

3. A client with a history of seizures is prescribed phenytoin (Dilantin). Which statement should the LPN/LVN include when teaching the client about this medication?

• A. Do not take the medication with milk to avoid reduced absorption.
• B. Brush and floss your teeth regularly to prevent gum disease.
• C. Avoid taking antacids within 2 hours of the medication.
• D. Report any unusual bleeding or bruising to the healthcare provider.

Correct answer: C

Rationale: The correct answer is to avoid taking antacids within 2 hours of phenytoin. Antacids can interfere with the absorption of phenytoin, reducing its effectiveness. Choice A is incorrect because phenytoin should not be taken with milk, as it may decrease its absorption. Choice B is unrelated to the medication and focuses on dental hygiene. Choice D is important but not directly related to phenytoin; it is more relevant to monitoring for adverse effects of the medication.

4. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe?

• A. Tops of the ears
• B. Bridge of the nose
• C. Around the nostrils
• D. Over the cheeks

Correct answer: A

Rationale: When a client is using a nasal cannula for oxygen therapy, the areas prone to skin damage are the tops of the ears and around the nostrils. The pressure exerted by the cannula on these areas can lead to skin breakdown, so it is important for the nurse to observe these sites for any signs of damage. The correct answer is 'Tops of the ears.' Choices 'Bridge of the nose' and 'Over the cheeks' are not typically areas where skin damage related to the cannula would occur, making them incorrect choices.

5. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B: 'Glasgow Coma Scale 8, respirations regular.' A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deep state of unconsciousness, which may not be accurate in this case. Choice C is incorrect as stating the client 'appears to be sleeping' may not accurately reflect the severity of the situation. Choice D is incorrect because a Glasgow Coma Scale of 13 would not typically correspond to a non-responsive state.

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