Nursing Elites

1. When assessing the respiratory system for complications of immobility, what action should the nurse take?

• A. Inspect chest wall movements primarily during the expiratory cycle.
• B. Auscultate the entire lung region to assess lung sounds.
• C. Focus auscultation on the upper lung fields.
• D. Assess the patient at least every 4 hours.

Correct answer: B

Rationale: The correct action for the nurse when assessing the respiratory system for complications of immobility is to auscultate the entire lung region. This approach allows the nurse to identify any diminished breath sounds, crackles, or wheezes that may indicate respiratory issues. Inspecting chest wall movements primarily during the expiratory cycle (Choice A) may not provide a comprehensive assessment of lung sounds. Focusing auscultation on the upper lung fields (Choice C) may miss important findings in the lower lung fields. Assessing the patient at least every 4 hours (Choice D) is important for monitoring overall patient condition but does not specifically address the assessment of respiratory complications related to immobility.

2. The nurse manager is reviewing medication documentation. Which of the following statements should the nurse plan to include in teaching?

• A. Use the complete name of the medication magnesium sulfate.
• B. Avoid abbreviating medication names to prevent errors.
• C. Use generic names only for medications.
• D. Document the dosage, route of administration, and complete medication name.

Correct answer: A

Rationale: The correct answer is A: 'Use the complete name of the medication magnesium sulfate.' When documenting medications, it is crucial to use the complete name to avoid confusion and errors. Abbreviating medication names (choice B) can lead to misinterpretation and errors in medication administration. Using generic names only for medications (choice C) may not provide enough specificity, leading to potential medication errors. While documenting the dosage and route of administration is important, it is also vital to include the complete medication name (choice D) for accurate record-keeping and to ensure clarity in medication administration.

3. Which of the following should a group of community health nurses plan as part of a primary prevention program for occupational pulmonary diseases?

• A. Screening for early symptoms
• B. Providing treatment for diagnosed conditions
• C. Elimination of the exposure
• D. Increasing awareness of symptoms

Correct answer: C

Rationale: The correct answer is C: 'Elimination of the exposure.' Primary prevention programs for occupational pulmonary diseases aim to prevent the development of these diseases by eliminating or minimizing exposure to harmful substances in the workplace. Screening for early symptoms (Choice A) focuses on secondary prevention, detecting diseases at an early stage. Providing treatment for diagnosed conditions (Choice B) is part of tertiary prevention, managing and treating established diseases. Increasing awareness of symptoms (Choice D) may help in early detection but does not directly address the prevention of exposure, which is crucial for primary prevention of occupational pulmonary diseases.

4. An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The LPN knows that the best position for this client during administration of the feedings is

• A. prone.
• B. Fowler's.
• C. Sims'.
• D. supine.

Correct answer: B

Rationale: Fowler's position is the optimal position for a client receiving tube feedings via a gastrostomy tube because it reduces the risk of aspiration. In Fowler's position, the client is sitting up at a 45- to 60-degree angle, which helps prevent the formula from flowing back into the esophagus and causing aspiration pneumonia. Choice A, prone position (lying face down), would not be suitable for administering tube feedings as it increases the risk of aspiration. Sims' position (lying on the left side with the right knee flexed) and supine position (lying flat on the back) are also not ideal for administering tube feedings as they do not provide the same level of protection against aspiration as Fowler's position does.

5. The healthcare provider is assessing a client diagnosed with rheumatoid arthritis. Which assessment finding would be most concerning?

• A. Morning stiffness
• B. Joint deformities
• C. Weight loss
• D. Fever

Correct answer: D

Rationale: Fever in a client with rheumatoid arthritis can indicate an underlying infection or a more serious systemic involvement, such as vasculitis or inflammation of internal organs. These conditions can lead to serious complications and require immediate medical attention. Joint deformities and morning stiffness are common manifestations of rheumatoid arthritis itself and may not be indicative of an acute issue. Weight loss can be seen in chronic inflammatory conditions like rheumatoid arthritis but is not as concerning as fever, which suggests an acute process requiring prompt evaluation and intervention.

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