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 client with a tracheostomy is being taught by a nurse and their family how to care for the tracheostomy at home. Which of the following should the nurse include in the teaching?

• A. Use tracheostomy covers when outdoors.
• B. Clean the tracheostomy with alcohol.
• C. Replace the tracheostomy tube every week.
• D. Cover the tracheostomy with a wet cloth when sleeping.

Correct answer: A

Rationale: Using tracheostomy covers when outdoors is essential to protect the tracheostomy from dust and debris, reducing the risk of infection. Tracheostomy covers help maintain cleanliness and prevent foreign particles from entering the stoma. Choice B is incorrect because cleaning the tracheostomy with alcohol can be too harsh and drying for the skin surrounding the stoma, leading to skin irritation. Choice C is incorrect as tracheostomy tubes are typically replaced only when clinically indicated or as per the healthcare provider's instructions, not routinely every week, to prevent unnecessary risks and complications. Choice D is incorrect as covering the tracheostomy with a wet cloth when sleeping can create a moist environment ideal for bacterial growth, increasing the risk of infection and skin breakdown. It is important to keep the tracheostomy site clean, dry, and protected to maintain optimal hygiene and prevent complications.

3. A client is contemplating retirement and expresses uncertainty about wanting to retire. Which of the following responses should the nurse make?

• A. Let’s talk about how the change in your job status will affect you.
• B. Have you considered the financial implications of retirement?
• C. What are your thoughts on retirement and how it may impact your life?
• D. Would you like to discuss potential activities you could engage in during retirement?

Correct answer: A

Rationale: Choosing option A, 'Let’s talk about how the change in your job status will affect you,' is the most appropriate response in this scenario. By discussing how retirement might affect the client, the nurse can address the client's concerns and emotions about the impending change. Option B, 'Have you considered the financial implications of retirement?' is not the best response as it focuses solely on financial aspects and does not address the client's emotional readiness for retirement. Option C, 'What are your thoughts on retirement and how it may impact your life?' is more open-ended and may not address the immediate concerns of the client expressing uncertainty. Option D, 'Would you like to discuss potential activities you could engage in during retirement?' assumes the client is certain about retiring and focuses on activities rather than addressing the client's feelings of uncertainty.

4. The nurse is preparing to administer a subcutaneous injection of enoxaparin (Lovenox). Which site is most appropriate for the LPN/LVN to use?

• A. Deltoid muscle
• B. Ventrogluteal site
• C. Abdomen
• D. Dorsogluteal site

Correct answer: C

Rationale: The abdomen is the most appropriate site for administering subcutaneous injections of enoxaparin (Lovenox). Enoxaparin is typically administered in the abdomen due to better absorption and reduced risk of injury to underlying structures. The deltoid muscle is not recommended for subcutaneous injections of enoxaparin due to the potential risk of injury to underlying structures. The ventrogluteal and dorsogluteal sites are more appropriate for intramuscular injections rather than subcutaneous injections.

5. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily?

• A. Spaghetti
• B. Watermelon
• C. Chicken
• D. Tomatoes

Correct answer: B

Rationale: The correct answer is B: Watermelon. Watermelon is high in potassium, which is important to eat daily when taking furosemide to prevent hypokalemia. Furosemide is a diuretic that can lead to potassium loss, so consuming potassium-rich foods like watermelon helps maintain adequate potassium levels. Spaghetti, chicken, and tomatoes are not as high in potassium and therefore not as beneficial in preventing hypokalemia related to furosemide use.

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