Nursing Elites

1. The nurse provides a postoperative client with an analgesic medication and darkens the room before the client goes to sleep for the night. The nurse's actions:

• A. help decrease stimuli from the cerebral cortex.
• B. stimulate hormonal changes in the brain.
• C. help the client's circadian rhythm.
• D. alert the hypothalamus in the brain.

Correct answer: A

Rationale: The nurse's actions of providing an analgesic medication and darkening the room aim to decrease stimuli from the cerebral cortex. Reduction of environmental stimuli, especially light and noise, from the cerebral cortex, which is an area of arousal, facilitates sleep. By decreasing input to this area, the client is more likely to fall asleep and stay asleep. Choices B, C, and D are incorrect because the scenario does not involve stimulating hormonal changes, influencing the circadian rhythm, or alerting the hypothalamus.

2. The LPN has been given assignments by the RN. Which assignment should the LPN question as being beyond the scope of the LPN?

• A. The LPN is assigned to care for a client with diabetes mellitus who needs instructions reinforced on how to self-administer insulin.
• B. The LPN is assigned to reinforce discharge teaching about dressing changes and medications to a 35-year-old man.
• C. The LPN is assigned to care for a 75-year-old woman, hospitalized for dehydration, who is being discharged home today with no medications.
• D. The LPN is assigned to care for a woman with newly diagnosed leukemia who will be receiving her initial dose of chemotherapy.

Correct answer: D

Rationale: The LPN should be able to recognize when an assignment is beyond their scope of practice. Administering chemotherapy for leukemia is not within the scope of practice for the LPN, and this assignment should be questioned. Choices A, B, and C are within the scope of practice for an LPN. Reinforcing teaching on self-administration of insulin, assisting with discharge instructions on dressing changes, and caring for a client being discharged with no medications are all appropriate tasks for an LPN.

3. A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?

• A. The history and presentation might indicate chickenpox, a highly contagious disease.
• B. The lesions might indicate a noncontagious infection that does not require isolation.
• C. The history and presentation might indicate an infectious illness called impetigo.
• D. The lesions are not contagious unless others have open wounds or lesions themselves.

Correct answer: C

Rationale: The scenario describes classic impetigo, characterized by maculopapular lesions with honey-colored drainage, typically caused by Staphylococcus aureus or Streptococcus pyogenes. Antibiotic therapy is usually indicated for impetigo. Chickenpox, a highly contagious disease, presents with a history of high fever followed by a vesicular rash, different from the described maculopapular lesions with honey-colored drainage. Choice A is incorrect as the presentation is not consistent with chickenpox. Choice B is incorrect because impetigo is contagious, especially through direct contact. Choice D is also incorrect as impetigo is a contagious skin infection regardless of others having open wounds or lesions.

4. A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?

• A. Ask the nursing assistant to complete an incident report
• B. Check the client's level of consciousness and vital signs
• C. Contact the unit secretary on the intercom and ask that the client's health care provider be called
• D. Ask the nursing assistant to assist in getting the client back to bed

Correct answer: B

Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice D) should only be considered after ensuring the client is stable and safe to move.

5. When caring for clients with Buck’s Traction, the major areas of importance should be:

• A. nutrition, elimination, comfort, safety
• B. ROM exercises, transportation
• C. nutrition, elimination, comfort, safety
• D. elimination, safety, isotonic exercises

Correct answer: C

Rationale: When caring for clients with Buck’s Traction, the major areas of importance should be nutrition, elimination, comfort, and safety. Proper nutrition, including a diet high in protein with adequate fluids, is essential for healing and recovery. Elimination refers to maintaining regular bowel and bladder function. Comfort is crucial to ensure the patient's well-being while in traction, and safety measures should be followed to prevent complications. Choices A, B, and D are incorrect. ROM exercises are not typically a primary concern with Buck’s Traction, making choices A and B incorrect. Isotonic exercises are not specifically related to the care of a client in Buck's Traction, making choice D incorrect.

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