Nursing Elites

1. The LPN is taking care of a client with a documented allergy to Penicillin. After rounds, the LPN notices that the client has an order for Cefazolin. Which of the following actions would be the least appropriate?

• A. The LPN clarifies the severity of the Penicillin allergy.
• B. The LPN discusses the order with the care team prior to administering Cefazolin.
• C. The LPN administers all ordered medications except for the Cefazolin.
• D. The LPN monitors the client after a test dose of Cefazolin is administered.

Correct answer: C

Rationale: The least appropriate action is for the LPN to administer all ordered medications except for the Cefazolin. The LPN should always consider the client's documented allergy to Penicillin seriously. It is crucial to discuss the order with the care team before administering Cefazolin to ensure patient safety. Administering a medication that could potentially cause harm due to a documented allergy is unsafe practice. While monitoring the client after a test dose of Cefazolin is important, it should not precede clarification with the care team regarding the allergy and the appropriateness of the medication. Therefore, withholding the Cefazolin is the most appropriate action in this scenario.

2. A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, "I do not know how to make my diet work with the kind of foods that my family eats."? What should the nurse do first to help the client determine a suitable diet for disease prevention?

• A. Provide her with copies of the approved dietary guidelines from the American Diabetic Association and the American Heart Association.
• B. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs.
• C. Provide a high-protein diet plan for the client.
• D. Provide the client with information related to risk factors for heart disease and diabetes.

Correct answer: B

Rationale: The correct answer is to ask the client to provide a list of the types of foods she eats to determine how to best meet her needs. Assessment is the first step in helping the client establish a suitable diet for disease prevention. By understanding the client's current dietary habits, the nurse can tailor recommendations based on the approved dietary guidelines from the American Diabetic Association and the American Heart Association. Providing a high-protein diet plan without assessing the client's current diet may not align with her cultural preferences or health goals. While educating the client on risk factors for heart disease and diabetes is essential, it is not the initial step in developing a personalized dietary plan.

3. A nurse reviewing the physical assessment findings in a client's health care record notes documentation that the Phalen test caused numbness and burning. Which disorder does the nurse, on the basis of this finding, conclude that the client has?

• A. Scoliosis
• B. Bone deformity
• C. Heberden nodules
• D. Carpal tunnel syndrome

Correct answer: D

Rationale: The Phalen test is specifically used to assess for carpal tunnel syndrome. In this test, the client is asked to hold their hands back to back while flexing the wrists 90 degrees, which can reproduce the numbness and burning sensation experienced by individuals with carpal tunnel syndrome. Scoliosis is a condition characterized by abnormal lateral curvature of the spine, not related to the Phalen test. Bone deformity is a general term that does not specifically relate to the symptoms described. Heberden nodules are bony swellings that occur in osteoarthritis and are not assessed through the Phalen test.

4. If Ms. Barrett's distance vision is 20/30, which of the following statements is true?

• A. The client can read from 20' what a person with normal vision can read at 30'.
• B. The client can read from 30' what a person with normal vision can read at 20'.
• C. The client can read the entire chart from 30'.
• D. The client can read the chart from 20' with the left eye and from 30' with the right eye.

Correct answer: A

Rationale: When Ms. Barrett's distance vision is measured as 20/30, it means that she can read from 20 feet away what a person with normal vision can read at 30 feet. The numerator (20) represents the distance in feet between the chart and the client, while the denominator (30) indicates the distance at which a normal eye can read the chart. In this case, Ms. Barrett's vision is slightly worse than normal, as she needs to be closer to the chart to read it clearly. Therefore, choice A is correct. Choices B, C, and D are incorrect: Choice B reverses the distances, Choice C assumes the client can read the entire chart from 30 feet, and Choice D introduces information not related to the 20/30 measurement.

5. A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health?

• A. The young adult is sensitive to criticism.
• B. The young adult verbalizes unrealistic fears.
• C. The young adult verbalizes disappointment with life.
• D. The young adult verbalizes satisfaction with friendships.

Correct answer: D

Rationale: The correct answer is that the young adult verbalizes satisfaction with friendships. Emotional health in young adults is characterized by various positive signs, including satisfaction with social interactions and friendships. Expressing contentment with friendships indicates a healthy emotional state, fostering positive social connections. On the other hand, sensitivity to criticism, verbalizing unrealistic fears, and expressing disappointment with life are all indicative of emotional distress and potential mental health challenges. These behaviors can hinder social relationships and overall emotional well-being.

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