Nursing Elites

1. The nurse is caring for a client who has dysphagia related to a stroke. The nurse works with the client to explain what food and beverages might minimize aspiration. What is this an example of?

• A. Health promotion
• B. Secondary prevention
• C. Tertiary prevention
• D. Primary prevention

Correct answer: B

Rationale: The nurse working with the client to explain what food and beverages might minimize aspiration is an example of secondary prevention. Secondary prevention involves early detection and intervention to prevent complications or worsening of a condition. In this case, the nurse is helping to prevent aspiration pneumonia by providing education and guidance on safe eating and drinking practices after the client has already experienced dysphagia due to a stroke. Choice A, health promotion, focuses on empowering individuals to adopt healthy behaviors to improve overall well-being and prevent illness. It is more about promoting general health rather than specific interventions related to a particular condition like dysphagia. Choice C, tertiary prevention, involves managing and rehabilitating a condition to prevent further complications or disabilities. In this scenario, the nurse is not yet addressing complications but rather actively preventing them. Choice D, primary prevention, aims to prevent the onset of a disease or condition before it occurs. The client in this case already has dysphagia, so the focus is on preventing further complications, making it a secondary prevention intervention.

2. The LPN is taking care of a 176-pound client who has recently been diagnosed with diabetes. The primary healthcare provider has written an order for Lantus� (insulin glargine injection) 100 units/mL, using weight-based dosing of 0.2 units/kg per day. The LPN should prepare ____ units for administration.

• A. 12
• B. 35
• C. 16
• D. 9

Correct answer: B

Rationale: To calculate the correct dosage, first convert the client's weight from pounds to kilograms. As 1 kg = 2.2 pounds, 176 pounds � 2.2 = 80 kg. The client should receive 0.2 units for every kilogram, which equals 16 units. Therefore, the total amount to prepare is 16 units x 100 units/mL = 1600 units. Considering the medication concentration of 100 units/mL, 1600 units � 100 units/mL = 16 mL. However, since the question asks for the number of units, the final answer is 16 units x 2 injections = 32 units. Therefore, the LPN should prepare 32 units for administration.

3. The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine?

• A. 6
• B. 8
• C. 12
• D. 16

Correct answer: C

Rationale: An 18-month-old child should have approximately 12 teeth. In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 - 6 = 12. The correct answer is 12. Choice A (6) is incorrect as it does not consider the child's age. Choices B (8) and D (16) are incorrect as they do not align with the dental development timeline and the specific age of the child in question.

4. A nurse assisting with data collection plans to assess tactile (vocal) fremitus. The nurse performs this by using which technique?

• A. Palpating for symmetric chest expansion
• B. Auscultating the breath sounds over the trachea and larynx
• C. Auscultating the breath sounds over the peripheral lung fields
• D. Palpating the thorax, comparing vibrations from side to side as the client repeats the word 'ninety-nine'

Correct answer: D

Rationale: To assess tactile (vocal) fremitus, the nurse palpates the thorax and compares vibrations from side to side as the client repeats the word 'ninety-nine.' This technique helps in evaluating the intensity and symmetry of vibrations felt. Palpating for symmetric chest expansion involves assessing the expansion of the chest during breathing by placing hands on the anterolateral wall. Auscultating the breath sounds over the trachea and larynx is done to assess bronchial breath sounds, while auscultating over the peripheral lung fields is used to assess vesicular breath sounds.

5. The nurse receives an order to administer phenytoin through the client's J-tube. The order instructs that tube feedings are stopped at least an hour prior to administering the medication and an hour after the medication is administered. Which of the following considerations may be a reason to discuss this order with the physician?

• A. The client has a history of Type II diabetes.
• B. The client is on a continuous tube-feeding regimen.
• C. The client is on fluid restriction.
• D. The pharmacy has provided phenytoin in tablet form.

Correct answer: B

Rationale: For a client on a continuous tube-feeding regimen, stopping tube feedings for two hours to administer this medication may compromise the client's nutritional status. This interruption can lead to inadequate nutrient intake, affecting the client's overall nutritional well-being. The other choices are less relevant in this situation. Type II diabetes does not directly impact the administration of phenytoin through a J-tube. Fluid restriction would not prevent the temporary interruption of tube feedings for medication administration. The form of phenytoin provided by the pharmacy does not impact the need to discuss the order with the physician regarding the client's continuous tube-feeding regimen.

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