Nursing Elites

1. The healthcare provider is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the healthcare provider take?

• A. Remove elastic stockings every 4 hours.
• B. Measure the calf circumference of both legs.
• C. Lightly rub the lower leg for redness and tenderness.
• D. Dorsiflex the foot while assessing for patient discomfort.

Correct answer: B

Rationale: The correct action when assessing an immobile patient for deep vein thromboses (DVTs) is to measure the calf circumference of both legs. This helps in detecting swelling or changes that may indicate the presence of a DVT. Removing elastic stockings every 4 hours (Choice A) is not necessary and can disrupt circulation. Lightly rubbing the lower leg for redness and tenderness (Choice C) can potentially dislodge a clot if present. Dorsiflexing the foot while assessing for patient discomfort (Choice D) is not a specific assessment for DVT and may not provide relevant information in this context.

2. An unlicensed assistive personnel (UAP) places a client in a left lateral position before administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP?

• A. Position the client on the right side of the bed in reverse Trendelenburg.
• B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
• C. Reposition the client in a Sim's position with the weight on the anterior ilium.
• D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Correct answer: C

Rationale: The correct instruction the LPN/LVN should provide to the UAP is to reposition the client in a Sim's position with the weight on the anterior ilium for administering a soap suds enema. This position helps facilitate the administration of the enema by providing better access and comfort for the client. Choice A is incorrect as reverse Trendelenburg is not the appropriate position for administering a soap suds enema. Choice B is incorrect as the concentration of soap in the enema solution is not specified and might be too strong. Choice D is incorrect as raising the side rails and elevating the bed does not directly relate to the proper positioning for administering the enema.

3. The nurse is caring for a client with a newly placed colostomy. Which statement by the client indicates a need for additional teaching?

• A. I will need to change the colostomy bag every day.
• B. I should avoid foods that can cause gas, such as beans and carbonated drinks.
• C. I need to empty the colostomy bag when it is one-third to one-half full.
• D. I will need to take care of the skin around the stoma to prevent irritation.

Correct answer: A

Rationale: The correct answer is A. Changing the colostomy bag every day is not necessary; it should be changed as needed, usually every 3-7 days. This statement indicates a need for additional teaching as frequent changes can irritate the skin and are not typically required. Choices B, C, and D are all correct statements regarding colostomy care. Avoiding gas-producing foods, emptying the bag when it is one-third to one-half full, and taking care of the skin around the stoma are all essential aspects of colostomy care to prevent complications and maintain skin integrity.

4. The patient is being taught about flossing and oral hygiene. What instruction will the nurse include in the teaching session?

• A. Using waxed floss helps prevent bleeding
• B. Flossing removes plaque and tartar from the teeth
• C. Flossing at least 3 times a day is beneficial
• D. Applying toothpaste before flossing is harmful

Correct answer: B

Rationale: The correct answer is B. Flossing is essential for removing plaque and tartar between teeth, contributing to better oral hygiene. Choice A is not entirely accurate as waxed floss may not solely prevent bleeding. Flossing three times a day, as mentioned in choice C, can be excessive and unnecessary, while choice D is incorrect as applying toothpaste before flossing is not harmful but might not provide additional benefits.

5. A 3-year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?

• A. Allergies
• B. Scabies
• C. Regression
• D. Pinworms

Correct answer: D

Rationale: The correct answer is D, Pinworms. Pinworms are a common cause of itching around the anal area, especially at night, in young children. Scratching the bottom and bedwetting can be indicative of a pinworm infection. Allergies (Choice A) are less likely given the symptoms described. Scabies (Choice B) may cause itching but is less common in causing bedwetting. Regression (Choice C) is not a common cause of these specific symptoms in a 3-year-old child.

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