Nursing Elites

1. An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question?

• A. Assisting a client who is 24 hr postop to use an incentive spirometer
• B. Collecting a clean catch urine specimen from a client who was admitted on the previous shift
• C. Providing nasopharyngeal suctioning for a client who has pneumonia
• D. Replacing the cartridge and tubing on a PCA pump

Correct answer: D

Rationale: The LPN should question the assignment of replacing the PCA pump cartridge and tubing as it is outside the LPN's scope of practice. LPNs are not trained to handle tasks related to PCA pumps, which involve medication administration and monitoring that are typically within the RN's responsibilities. Assisting a postop client with an incentive spirometer (Choice A), collecting a clean catch urine specimen (Choice B), and providing nasopharyngeal suctioning for a client with pneumonia (Choice C) are all tasks that fall within the LPN's scope of practice and do not require questioning by the LPN.

2. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?

• A. Total bilirubin.
• B. Urine ketones.
• C. Serum potassium.
• D. Platelet count.

Correct answer: C

Rationale: The correct answer is C: Serum potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Therefore, the nurse should monitor the client's serum potassium levels to prevent hyperkalemia, which can be a potential side effect of spironolactone. Monitoring total bilirubin levels (A) is not specifically required for clients taking spironolactone. Urine ketones (B) are not directly influenced by spironolactone use. Platelet count (D) is not typically monitored in clients taking spironolactone.

3. What is the role of the nurse in the care of a patient with a pressure ulcer?

• A. Clean the wound and apply a protective dressing
• B. Assess the wound and reposition the patient frequently
• C. Apply pressure to the ulcer and monitor for signs of healing
• D. Provide pain relief and administer antibiotics as needed

Correct answer: B

Rationale: The correct answer is B: Assess the wound and reposition the patient frequently. When caring for a patient with a pressure ulcer, it is crucial for the nurse to assess the wound regularly to monitor its progress and prevent complications. Additionally, repositioning the patient frequently helps to relieve pressure on the affected area, prevent further damage, and promote healing. Choice A is incorrect because while cleaning the wound is important, applying a protective dressing is not the primary role of the nurse in managing a pressure ulcer. Choice C is incorrect as applying pressure to the ulcer is harmful, and monitoring for signs of healing should not involve applying pressure. Choice D is incorrect as providing pain relief and administering antibiotics may be necessary but are not the primary interventions for managing a pressure ulcer.

4. A client has developed phlebitis at the IV site. What is the most appropriate next step?

• A. Apply a warm compress over the IV site
• B. Notify the provider and discontinue the IV infusion
• C. Increase the IV flow rate to clear the blockage
• D. Elevate the extremity and apply an ice pack

Correct answer: B

Rationale: Phlebitis, inflammation of a vein, is a complication that requires prompt action. The most appropriate next step is to discontinue the IV infusion and notify the healthcare provider. Applying a warm compress, increasing the IV flow rate, or applying an ice pack are not appropriate interventions for phlebitis. Warm compresses may worsen inflammation, increasing the IV flow rate could exacerbate the condition, and ice packs are not recommended for phlebitis.

5. A client has developed phlebitis at the IV site. What should the nurse do first?

• A. Apply a warm compress to the IV site
• B. Discontinue the IV and notify the provider
• C. Monitor the IV site for signs of infection
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the priority action for the nurse is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and removing the IV can help prevent further complications. Applying a warm compress may provide symptomatic relief but does not address the root cause. Monitoring for infection is important, but immediate action to remove the source of inflammation is crucial. Administering an anti-inflammatory medication is not the first-line intervention for phlebitis; removal of the IV is necessary.

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