Nursing Elites

1. The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?

• A. history of dizziness
• B. need for a wheelchair due to reduced mobility
• C. weakness and fatigue noted when climbing stairs
• D. intact recent and remote memory

Correct answer: D

Rationale: The correct answer is intact recent and remote memory. Intact memory function indicates that the client is less likely to be at risk for falls as it suggests cognitive awareness and orientation, which are important for safety. Choices A, B, and C are risk factors for falls: a history of dizziness can lead to imbalance, the need for a wheelchair due to reduced mobility can increase fall risk, and weakness and fatigue when climbing stairs indicate physical limitations that predispose a client to falls. Therefore, these options would suggest an increased risk for falls.

2. The LPN is caring for a 32-year-old female client who is 8 hours post-op after a tonsillectomy. Which of these actions would be appropriate for the nurse to take?

• A. Inform the client that ear pain may occur and is normal.
• B. Provide ice water and a straw to promote easy fluid consumption.
• C. Provide hot tea to soothe the throat.
• D. Monitor vitals every 15 minutes.

Correct answer: A

Rationale: The appropriate action for the nurse to take is to inform the client that ear pain may occur and is normal after a tonsillectomy. Referred pain in the ear is common due to related nerve pathways. It is essential to educate the client about this to alleviate concerns. Providing ice water and a straw is not recommended as they may irritate the throat and disturb the healing process. Hot beverages like tea should also be avoided for the same reason. While monitoring vitals every 15 minutes is crucial in the immediate postoperative period for early identification of any complications, it is not the most appropriate action in this scenario where addressing the client's concerns and providing education is key.

3. Which of these clients should the LPN/LVN see first?

• A. a client with a newly placed NG tube who is complaining of pain around the face and a plugged nose
• B. a post-op prostatectomy client who complains of bladder spasms and blood in his foley bag
• C. a client in an arm cast who is 2 days post-op and reports feelings of numbness and tingling in her affected arm
• D. a client newly diagnosed with Hepatitis A who reports stomach pain and itchy skin

Correct answer: C

Rationale: Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a medical provider right away. This is a potential emergency situation that requires immediate attention to prevent complications. The other options present expected or typical symptoms related to their diagnosis, which do not require immediate intervention. Complaints related to a newly placed NG tube such as pain around the face and a plugged nose may require assessment and intervention but are not as urgent as potential compartment syndrome. Bladder spasms and blood in the foley bag post-prostatectomy are common postoperative issues that can be addressed after the client in the arm cast with potential compartment syndrome is seen. Stomach pain and itchy skin in a client with Hepatitis A are common symptoms of the condition and do not indicate an emergency situation.

4. A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?

• A. turning off the room light and closing the door
• B. engaging the child in calming activities before bedtime
• C. identifying the child's home bedtime rituals and following them
• D. encouraging relaxation techniques like deep breathing exercises

Correct answer: C

Rationale: For a 4-year-old client struggling to sleep in the hospital, the best nursing intervention is to identify the child's home bedtime rituals and follow them. Preschool-age children often have specific bedtime routines that provide comfort and promote sleep. This familiarity can help create a sense of security in an unfamiliar hospital environment. Choice A, turning off the room light and closing the door, may increase the child's fear of the dark and being alone. Choice B, engaging the child in calming activities before bedtime, is a better choice than tiring them with play exercises. Choice D, encouraging relaxation techniques like deep breathing exercises, although helpful, may not be as effective as following the child's familiar bedtime routines.

5. After assigning tasks, what is the nurse's primary responsibility?

• A. Assigning any tasks that were not completed to the next nursing shift
• B. Documenting completion of each task
• C. Allowing each staff member to make judgments when performing the tasks
• D. Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task

Correct answer: D

Rationale: The nurse's primary responsibility after assigning tasks is to follow up with each staff member regarding the task's performance and outcomes. This ensures accountability and quality care delivery. Allowing staff members to make judgments independently can compromise patient safety if they lack the necessary knowledge or experience. While documenting task completion is important, it should follow the follow-up to assess outcomes. Assigning incomplete tasks to the next shift is not ideal as it may result in unmet patient needs and increased workload for the next shift.

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