Nursing Elites

1. The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?

• A. Place a pillow under the patient's lower legs.
• B. Turn the head toward one side with a large, soft pillow.
• C. Position legs flat against the bed.
• D. Raise the head of the bed to 45 degrees.

Correct answer: A

Rationale: Placing a pillow under the patient's lower legs when in the prone position is essential to allow dorsiflexion of the ankles and some knee flexion, which promote relaxation. This position also helps in maintaining proper alignment of the spine. Options B, C, and D are incorrect because turning the head, positioning legs flat against the bed, and raising the head of the bed to 45 degrees are not appropriate actions for a patient in the prone position. Turning the head to one side with a large, soft pillow is commonly done for patients in the supine position to maintain proper alignment and airway patency. Positioning legs flat against the bed is more suitable for a patient in a supine or semi-fowler's position. Raising the head of the bed to 45 degrees is typically done for patients who need semi-fowler's positioning for respiratory support or to prevent aspiration.

2. A healthcare professional uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking did the healthcare professional demonstrate?

• A. Confidence
• B. Perseverance
• C. Integrity
• D. Discipline

Correct answer: D

Rationale: The correct answer is 'Discipline.' In this scenario, discipline is exemplified by following a structured and comprehensive assessment process, as seen in the head-to-toe approach. Confidence (choice A) relates to self-assurance and belief in one's abilities, which is not the primary critical thinking demonstrated in this situation. Perseverance (choice B) is the persistence in achieving goals despite challenges, not directly related to the systematic assessment process. Integrity (choice C) pertains to honesty and ethical behavior, which are important traits but not the critical thinking skill exemplified by the structured assessment process shown in the head-to-toe approach.

3. A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?

• A. A client who has new onset of dyspnea 24 hours after a total hip arthroplasty
• B. A client who has acute abdominal pain rated 4 on a scale from 0 to 10
• C. A client who has a UTI and low-grade fever
• D. A client who has pneumonia and an oxygen saturation of 96%

Correct answer: A

Rationale: The nurse should see the client who has new onset of dyspnea 24 hours after a total hip arthroplasty first. New onset of dyspnea, especially after surgery, can indicate a serious complication such as a pulmonary embolism or deep vein thrombosis. It is essential to assess this client promptly to rule out potentially life-threatening conditions. Acute abdominal pain, a UTI with low-grade fever, and pneumonia with an oxygen saturation of 96% are important issues but do not indicate the urgency and potential severity of a post-operative complication like pulmonary embolism or deep vein thrombosis.

4. A client with a history of severe anxiety is scheduled for surgery. Which preoperative medication is the most appropriate for the LPN/LVN to administer to this client?

• A. Lorazepam (Ativan)
• B. Morphine sulfate
• C. Meperidine (Demerol)
• D. Promethazine (Phenergan)

Correct answer: A

Rationale: Lorazepam (Ativan) is the most appropriate preoperative medication for a client with severe anxiety. Lorazepam belongs to the benzodiazepine class and is commonly used to manage anxiety before surgical procedures due to its anxiolytic properties. Morphine sulfate and Meperidine (Demerol) are opioid analgesics, not typically indicated for preoperative anxiety. Promethazine (Phenergan) is an antihistamine used for nausea and vomiting, not anxiety management.

5. The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?

• A. Infuse normal saline at a keep-vein-open rate.
• B. Discontinue the IV and flush the port with heparin.
• C. Infuse 10% dextrose and water at 54 ml/hr.
• D. Obtain a stat blood glucose level and notify the healthcare provider.

Correct answer: C

Rationale: Infusing 10% dextrose and water at 54 ml/hr is the correct action to prevent hypoglycemia until the next TPN solution becomes available. This solution will help maintain the client's glucose levels. Infusing normal saline at a keep-vein-open rate (Choice A) is not appropriate for maintaining glucose levels and would not address the nutritional needs provided by TPN. Discontinuing the IV and flushing the port with heparin (Choice B) is unnecessary and not indicated in this situation as the client still needs fluid and nutrition. Obtaining a stat blood glucose level and notifying the healthcare provider (Choice D) can be done later but is not the immediate action required when the TPN solution has run out.

Similar Questions