Nursing Elites

1. The charge nurse on the unit observes that one of the staff nurses is not using proper hand washing techniques. Which is the most appropriate initial approach to correct the behavior?

• A. Remind the nurse that proper hand washing prevents infection
• B. Discuss what the nurse knows about proper hand hygiene
• C. Provide a review of the hand washing policy
• D. Refer the nurse to the infection control nurse

Correct answer: B

Rationale: The most appropriate initial approach to correct the behavior of improper hand washing by a staff nurse is to discuss what the nurse knows about proper hand hygiene. This approach helps in identifying any knowledge gaps the nurse may have and provides an opportunity to educate and correct the behavior. Option A is not the best choice as simply reminding the nurse about the importance of hand washing may not address the underlying issue of knowledge or technique. Option C, providing a review of the hand washing policy, may be necessary but is not the most immediate step to take. Option D, referring the nurse to the infection control nurse, is premature and may not be necessary if the issue can be resolved through education and communication first.

2. A client with a history of deep vein thrombosis (DVT) is admitted with swelling and pain in the left leg. What is the most appropriate action for the LPN/LVN to take?

• A. Apply warm compresses to the affected leg.
• B. Elevate the left leg above the level of the heart.
• C. Measure the circumference of the left leg.
• D. Administer pain medication as prescribed.

Correct answer: C

Rationale: Measuring the circumference of the left leg is the most appropriate action for an LPN/LVN when assessing a client with a history of DVT and presenting with swelling and pain in the left leg. This measurement helps to assess the extent of swelling objectively and monitor changes in the client's condition. Applying warm compresses (Choice A) may worsen the condition by potentially promoting clot development. Elevating the left leg above the level of the heart (Choice B) is generally recommended for DVT to improve venous return, but measuring the circumference is more appropriate in this scenario. Administering pain medication (Choice D) does not address the underlying issue and should not be the initial action taken.

3. The LPN/LVN is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which observation indicates that the client is experiencing oxygen toxicity?

• A. Nasal congestion
• B. Cough
• C. Sore throat
• D. Fatigue

Correct answer: C

Rationale: The correct answer is 'C: Sore throat.' Oxygen toxicity can manifest with symptoms like a sore throat, cough, chest pain, difficulty breathing, and fatigue. However, a sore throat can be an early indicator of oxygen toxicity and should prompt immediate attention. Nasal congestion, cough, and fatigue are not specific indicators of oxygen toxicity but could be related to other factors in a client with COPD receiving oxygen therapy.

4. A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client’s record first?

• A. Assessment
• B. History of present illness
• C. Plan of care
• D. Admission date and time

Correct answer: D

Rationale: When admitting a client to a medical-surgical unit, documenting the admission date and time is crucial as it establishes the timeline for the client's care. This information ensures accurate tracking of interventions and facilitates communication among the healthcare team. While assessment, history of present illness, and plan of care are important components of the admission process, documenting the admission date and time takes priority to establish a baseline for care delivery. Without the admission date and time, the continuity of care and coordination among healthcare providers may be compromised.

5. A client is scheduled for a bronchoscopy. After the nurse explains the procedure, which statement by the client indicates a need for further teaching?

• A. I'm glad I don’t have to lie still for this procedure.
• B. I will have a local anesthetic to help with discomfort.
• C. I hope I get some medicine to relax me.
• D. I can't eat or drink for 6 hours before the procedure.

Correct answer: A

Rationale: The correct answer is A because the client's statement indicates a misunderstanding about the need to lie still during the bronchoscopy procedure. The client actually needs to remain still for the procedure to ensure its accuracy and safety. Choices B, C, and D demonstrate an understanding of the procedure by acknowledging the local anesthetic for discomfort, the possibility of receiving medicine for relaxation, and the requirement to fast before the procedure, respectively.

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