Nursing Elites

1. During a physical assessment on a toddler, what should be the first action?

• A. Perform traumatic procedures
• B. Use minimal physical contact
• C. Proceed from head to toe
• D. Explain the exam in detail

Correct answer: B

Rationale: The correct first action when performing a physical assessment on a toddler is to use minimal physical contact. This approach helps the toddler become comfortable and reduces anxiety during the assessment. Traumatic procedures (Choice A) should never be the first action as they can cause distress. Proceeding from head to toe (Choice C) is a common sequence in physical assessments but does not address the initial need to establish trust and comfort. Explaining the exam in detail (Choice D) is important but should come after establishing a rapport through minimal physical contact.

2. A client with limited mobility in his lower extremities is being cared for by a nurse. Which of the following actions should the nurse take to prevent skin breakdown?

• A. Place the client in high-Fowler's position
• B. Increase the client's intake of carbohydrates
• C. Massage the reddened areas with unscented lotion
• D. Have the client use a trapeze bar when changing positions

Correct answer: D

Rationale: The correct answer is to have the client use a trapeze bar when changing positions. This action helps in repositioning without causing friction or shearing, which can lead to skin breakdown. Placing the client in high-Fowler's position (Choice A) may not directly prevent skin breakdown related to limited mobility. Increasing carbohydrate intake (Choice B) is not relevant to preventing skin breakdown. Massaging reddened areas with lotion (Choice C) can potentially cause more harm by increasing friction and damaging the skin further, rather than preventing breakdown.

3. A client with a history of heart failure is admitted with weight gain and peripheral edema. Which medication should the LPN/LVN anticipate being prescribed?

• A. Lisinopril (Zestril)
• B. Furosemide (Lasix)
• C. Metoprolol (Lopressor)
• D. Simvastatin (Zocor)

Correct answer: B

Rationale: Furosemide (Lasix) is the correct answer. In a client with heart failure experiencing weight gain and peripheral edema, the priority is to manage fluid overload. Furosemide is a loop diuretic commonly prescribed to reduce excess fluid in heart failure patients. Lisinopril (Zestril) is an ACE inhibitor used to treat hypertension and heart failure but does not directly address fluid overload. Metoprolol (Lopressor) is a beta-blocker that helps manage heart failure symptoms but does not primarily target fluid retention. Simvastatin (Zocor) is a statin used to lower cholesterol levels and is not indicated for managing fluid overload in heart failure.

4. A client with heart failure and a new prescription for hydrochlorothiazide is receiving discharge teaching about safety considerations from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “I will take a hot bath before going to bed.”
• B. “I will take my new medication in the evening.”
• C. “I will leave a light on in my bathroom at night.”
• D. “I will weigh myself once weekly.”

Correct answer: C

Rationale: The correct answer is C. Leaving a light on in the bathroom at night is important for an older adult with heart failure who is taking hydrochlorothiazide, a diuretic that can cause nocturia. This safety measure helps prevent falls during nighttime bathroom visits. Option A is incorrect because taking a hot bath before bed can increase the risk of falls due to potential dizziness. Option B does not directly relate to safety considerations but rather the timing of medication administration. Option D, weighing oneself once weekly, is important for monitoring fluid retention but does not address safety concerns related to nocturia and falls.

5. A 2-year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?

• A. Place the child on clear liquids and gelatin for 24 hours
• B. Continue with the regular diet and include oral rehydration fluids
• C. Give bananas, apples, rice, and toast as tolerated
• D. Place NPO for 24 hours, then rehydrate with milk and water

Correct answer: B

Rationale: In managing mild diarrhea in a 2-year-old child, it is important to maintain their regular diet and include oral rehydration fluids. Choice A of placing the child on clear liquids and gelatin for 24 hours may not provide adequate nutrition and can lead to further electrolyte imbalances. Choice C of giving bananas, apples, rice, and toast as tolerated is a part of the BRAT diet, which is not recommended as the primary approach anymore due to its limited nutritional value. Choice D of placing the child NPO for 24 hours and then rehydrating with milk and water is not appropriate as it can worsen dehydration and delay recovery. Therefore, the best option is to continue the child's regular diet while incorporating oral rehydration fluids to prevent dehydration and maintain nutritional status.

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