Nursing Elites

1. An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the LPN/LVN implement first?

• A. Reaffirm the client's desire for no resuscitative efforts.
• B. Transfer the client to a hospice inpatient facility.
• C. Prepare the family for the client's impending death.
• D. Notify the healthcare provider of the family's request.

Correct answer: D

Rationale: The first action the LPN/LVN should implement is to notify the healthcare provider of the family's request. This is crucial to ensure that appropriate steps are taken to address the family's request for hospice care and to coordinate the necessary care for the resident. While reaffirming the client's desire for no resuscitative efforts is important, notifying the healthcare provider takes precedence in this situation. Transferring the client to a hospice inpatient facility and preparing the family for the client's impending death are significant actions but should be done after notifying the healthcare provider to ensure proper coordination of care.

2. A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

• A. Dissolve each medication in 5 mL of sterile water.
• B. Draw up each medication separately in the syringe.
• C. Push the syringe plunger gently if feeling resistance.
• D. Flush the tube with 15 mL of sterile water.

Correct answer: D

Rationale: The correct action the nurse should take when administering multiple medications to a client with an enteral feeding tube is to flush the tube with 15-30 mL of sterile water before and between medications, and 30-60 mL after the last medication. This helps prevent clogging and ensures each medication is delivered effectively. Choice A is incorrect as medications should not be dissolved in water for administration through an enteral feeding tube. Choice B is incorrect because each medication should be drawn up and administered separately to prevent any potential interactions. Choice C is incorrect as resistance while pushing the plunger may indicate a problem that needs to be addressed before continuing with the administration.

3. When using an open irrigation technique for a client's catheter, what action should the nurse take?

• A. Subtract the amount of irrigant used from the client's urine output.
• B. Add the amount of irrigant used to the urine output measurement.
• C. Measure the amount of irrigant used separately from the urine output.
• D. Document the total amount of fluid used for irrigation only.

Correct answer: A

Rationale: The correct action for the nurse to take when using an open irrigation technique for a client's catheter is to subtract the amount of irrigant used from the client's urine output. This subtraction helps accurately assess the client's output by accounting for the volume of irrigant introduced. Choice B is incorrect because adding the irrigant to the urine output measurement would falsely inflate the total output, leading to inaccurate assessment. Choice C is incorrect as measuring the amount of irrigant separately does not provide an accurate assessment of the client's total output as it disregards the irrigant's contribution. Choice D is incorrect as documenting the total fluid used for irrigation only does not differentiate between the irrigant and the client's actual urine output, which is crucial for accurate monitoring and assessment.

4. When documenting client care, which of the following abbreviations should be used?

• A. SS for sliding scale
• B. BRP for bathroom privileges
• C. OJ for orange juice
• D. SQ for subcutaneous

Correct answer: B

Rationale: When documenting client care, it is crucial to use standardized abbreviations to ensure clear communication and prevent misunderstandings. BRP for bathroom privileges is a recognized and commonly used abbreviation in healthcare settings. Choice A, SS for sliding scale, is not a standard abbreviation and can lead to confusion as it could be mistaken for other meanings. Choice C, OJ for orange juice, is informal and may not be universally understood in a healthcare context. Choice D, SQ for subcutaneous, is a valid abbreviation but may not be as relevant in the context of documenting client care compared to BRP, which is more specific and widely accepted.

5. When providing a bath, in which order will the nurse clean the body, beginning with the first area?

• A. Face
• B. Eyes
• C. Perineum
• D. Back and buttocks

Correct answer: B

Rationale: The correct sequence for giving a bath starts with cleaning the eyes, followed by the face, both arms, chest, hands/nails, abdomen, both legs, perineal hygiene, back, and finally the buttocks/anus. Therefore, the first area to be cleaned during a bath is the eyes. Choices A, C, and D are incorrect as per the standard procedure for providing a bath.

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