Nursing Elites

1. The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver's license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next?

• A. Stand to the side of the patient's eye and observe the cornea.
• B. Conclude that the glasses were lost during the accident.
• C. Notify the ambulance personnel about the missing glasses.
• D. Ask the patient where the glasses are.

Correct answer: A

Rationale: In this scenario, the nurse should stand to the side of the patient's eye and observe the cornea. This action is crucial in assessing whether the patient wears contact lenses, especially in unresponsive patients. Observing the cornea can provide valuable information about the patient's eye health and potential use of contact lenses. Choices B, C, and D are incorrect. Concluding that the glasses were lost during the accident is premature without proper assessment. Notifying ambulance personnel about the missing glasses may not be the immediate priority, and asking the unresponsive patient about the glasses would not yield useful information in this situation.

2. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

• A. Second intercostal space to the right of the sternum
• B. Fifth intercostal space at the midclavicular line
• C. Left sternal border
• D. Fifth intercostal space at the anterior axillary line

Correct answer: B

Rationale: The correct placement to auscultate the aortic valve is at the second intercostal space to the right of the sternum, which coincides with the aortic area. The choice stating 'Fifth intercostal space at the midclavicular line' is the correct answer for auscultating the aortic valve. Placing the stethoscope at the left sternal border would be more suitable for listening to the tricuspid valve. The fifth intercostal space at the anterior axillary line is the recommended area for auscultating the mitral valve. Therefore, choice B is the correct answer for assessing the aortic valve in a client with a history of a heart murmur related to aortic valve stenosis.

3. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take?

• A. Encourage the patient to engage in self-care.
• B. Promote mobility in the patient.
• C. Encourage the patient to perform range of motion exercises.
• D. Assist the patient with comfort measures.

Correct answer: D

Rationale: The priority action for a patient with Impaired physical mobility related to pain is to assist the patient with comfort measures. By addressing pain through comfort measures, the patient will be more willing and able to move. Encouraging self-care (Choice A) may be important but addressing pain first is crucial in improving mobility. Promoting mobility (Choice B) and encouraging range of motion exercises (Choice C) are important but addressing the pain and providing comfort measures take precedence to improve the patient's physical mobility.

4. A nurse in a provider's office is collecting information from an older adult who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?

• A. Liver damage
• B. Renal failure
• C. Gastric bleeding
• D. Heart attack

Correct answer: A

Rationale: Correct Answer: Large doses of acetaminophen can cause liver damage, which is a known adverse effect of the medication. Acetaminophen is metabolized in the liver, and excessive amounts can overwhelm the liver's ability to process it, leading to hepatotoxicity. Renal failure (Choice B) is not typically associated with acetaminophen use. Gastric bleeding (Choice C) is more commonly linked to nonsteroidal anti-inflammatory drugs (NSAIDs) rather than acetaminophen. Heart attack (Choice D) is not a recognized adverse effect of acetaminophen, which primarily affects the liver when taken in large amounts.

5. A client with osteoporosis is prescribed alendronate (Fosamax). What instruction should the LPN/LVN provide to the client?

• A. Take the medication with a full glass of water.
• B. Take the medication at bedtime.
• C. Take the medication with food.
• D. Take the medication on an empty stomach.

Correct answer: A

Rationale: The correct instruction for a client prescribed alendronate (Fosamax) is to take the medication with a full glass of water. Alendronate can cause irritation to the esophagus, so it is important to take it with a full glass of water and remain upright for at least 30 minutes after taking the medication to help prevent this irritation. Taking the medication at bedtime (choice B) may increase the risk of esophageal irritation as lying down can allow the medication to remain in the esophagus longer. Taking the medication with food (choice C) or on an empty stomach (choice D) can also interfere with the absorption of alendronate, reducing its effectiveness in treating osteoporosis.

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