Nursing Elites

1. The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?

• A. Maintain a narrow base of support.
• B. Dangle the patient at the bedside.
• C. Encourage isometric exercises.
• D. Suggest a high-calcium diet.

Correct answer: B

Rationale: The correct action the nurse should take first when a patient needs to be mobilized after being in bed for several days is to dangle the patient at the bedside. Dangling at the bedside is the initial step to assess the patient's tolerance to sitting up and moving. It helps prevent orthostatic hypotension and allows the nurse to evaluate the patient's response to upright positioning before attempting further ambulation. Maintaining a narrow base of support (Choice A) is related to assisting with ambulation but is not the first step. Encouraging isometric exercises (Choice C) and suggesting a high-calcium diet (Choice D) are not immediate actions needed to initiate mobilization in this scenario.

2. A middle-aged adult in a clinical setting mentions being at average risk for colon cancer and asks about routine screening. What should the nurse recommend?

• A. Performing a blood sample for a screening test.
• B. Scheduling a colonoscopy starting at age 60.
• C. Undergoing a fecal occult blood test annually.
• D. Having a sigmoidoscopy every 10 years.

Correct answer: C

Rationale: The correct answer is C. Colorectal cancer screening for individuals at average risk typically begins at age 50. One of the recommended options for routine screening is a fecal occult blood test done annually. Choice A is incorrect as blood samples are not used for routine colorectal cancer screening. Choice B is incorrect because colonoscopies usually start at age 50, not 60. Choice D is incorrect as sigmoidoscopies are recommended every 5 years, not every 10 years, for individuals at average risk for colon cancer.

3. A 15-year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching?

• A. I will only have to wear this for 6 months.
• B. I should inspect my skin daily.
• C. The brace will be worn day and night.
• D. I can take it off when I shower.

Correct answer: A

Rationale: The correct answer is A. The statement 'I will only have to wear this for 6 months' indicates a need for additional teaching because the Milwaukee Brace is typically worn for 12-18 months, not just 6 months. Choice B is correct as inspecting the skin daily is important to prevent skin breakdown. Choice C is correct as the brace is usually worn day and night for effectiveness. Choice D is correct as the brace can be removed when showering to maintain hygiene.

4. Prior to a client being transported for a chest x-ray, what should a healthcare professional do first?

• A. Identify the client using two identifiers
• B. Confirm the client's fasting status
• C. Check the client's allergies to contrast media
• D. Explain the procedure to the client

Correct answer: A

Rationale: Identifying the client using two identifiers is the crucial first step to ensure correct patient identification before any procedure. This process helps prevent errors and ensures that the right procedure is performed on the right patient. Confirming the client's identity is the top priority before addressing other aspects such as fasting status, allergies, or explaining the procedure. While confirming fasting status and checking for allergies are important, they are secondary to confirming the client's identity. Explaining the procedure to the client is also essential but should occur after ensuring proper identification.

5. The client is receiving total parenteral nutrition (TPN). Which laboratory value should the LPN/LVN monitor closely to assess for complications?

• A. Serum potassium
• B. Blood glucose
• C. Serum sodium
• D. Serum calcium

Correct answer: B

Rationale: The correct answer is B: Blood glucose. When caring for a client receiving total parenteral nutrition (TPN), monitoring blood glucose levels is essential due to the risk of hyperglycemia. TPN solutions are high in glucose, and clients may be at risk of developing hyperglycemia if the infusion rate is too high or if there are underlying issues such as insulin resistance. Monitoring serum potassium (choice A) is important but not the most crucial value to monitor in clients receiving TPN. Serum sodium (choice C) and serum calcium (choice D) are not directly impacted by TPN administration and are less likely to be affected compared to blood glucose levels.

Similar Questions