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 is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

• A. Ventrogluteal
• B. Dorsogluteal
• C. Deltoid
• D. Vastus lateralis

Correct answer: A

Rationale: The ventrogluteal site is considered the safest for intramuscular injections in young adult clients due to its location away from major nerves and blood vessels. The ventrogluteal site is preferred over the dorsogluteal site, as the latter is associated with a higher risk of injury to the sciatic nerve. The deltoid site is commonly used for vaccines but may not be suitable for all intramuscular injections due to smaller muscle mass. The vastus lateralis site is often used in infants and young children, but in young adults, the ventrogluteal site is preferred for safety and efficacy.

3. When should the nurse plan to collect a sputum specimen for culture and sensitivity as ordered by a client's provider?

• A. In the morning upon rising.
• B. Immediately after the client eats breakfast.
• C. Before the client goes to bed.
• D. After the client has had a drink of water.

Correct answer: A

Rationale: The correct time to collect a sputum specimen for culture and sensitivity is in the morning upon rising. This timing ensures the most concentrated sample as sputum produced overnight tends to accumulate and sit in the airways, providing a quality sample for testing. Collecting the specimen immediately after eating breakfast (choice B) may introduce food particles that could contaminate the sample. Collecting it before bed (choice C) may lead to a diluted sample due to daily activities. Collecting the specimen after having a drink of water (choice D) can also result in a diluted sample, impacting the accuracy of the test results.

4. A client with a history of heart failure presents with increased shortness of breath and swelling in the legs. What is the most important assessment for the LPN/LVN to perform?

• A. Monitor the client's oxygen saturation level.
• B. Assess the client's apical pulse.
• C. Check for jugular vein distention.
• D. Measure the client's urine output.

Correct answer: C

Rationale: Checking for jugular vein distention is crucial in assessing fluid overload in clients with heart failure. Jugular vein distention indicates increased central venous pressure, which can be a sign of worsening heart failure. Monitoring oxygen saturation (Choice A) is important but may not provide immediate information on fluid status. Assessing the apical pulse (Choice B) is relevant for monitoring heart rate but may not directly indicate fluid overload. Measuring urine output (Choice D) is essential for assessing renal function and fluid balance but does not provide immediate information on fluid overload in this scenario.

5. When assessing a client's skin turgor, a nurse should:

• A. Grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression
• B. Check skin elasticity on the back of the hand
• C. Press on the skin over the abdomen
• D. Measure skin turgor on the lower leg

Correct answer: A

Rationale: Correct answer: When assessing a client's skin turgor, a nurse should grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression. This method is reliable for evaluating hydration status as it is less influenced by age-related skin changes or adipose tissue. Choice B, checking skin elasticity on the back of the hand, is not the preferred method for assessing skin turgor. Choice C, pressing on the skin over the abdomen, is not a standard location for assessing skin turgor. Choice D, measuring skin turgor on the lower leg, is not a recommended site for assessing skin turgor in clinical practice.

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