Nursing Elites

1. The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient's nursing diagnosis is Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which nursing intervention is most appropriate for this patient?

• A. Obtain assistance and physically transfer the patient to the chair.
• B. Assist with ambulation and measure how far the patient walks.
• C. Give pain medication after ambulation so the patient will have a clear mind.
• D. Bring the patient to the cafeteria for group instruction on ambulation.

Correct answer: B

Rationale: The most appropriate nursing intervention for this patient is to assist with ambulation and measure how far the patient walks. This intervention helps quantify the patient's progress in mobility and rehabilitation. Choice A is incorrect because physically transferring the patient does not focus on promoting independence or assessing progress. Choice C is inappropriate as pain medication should be given based on scheduled times or as needed, not specifically after ambulation. Choice D is not suitable as group instruction on ambulation is not as individualized or focused on the patient's current needs and abilities.

2. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the LPN have for planning care in terms of the client's beliefs?

• A. Autopsy of the body is prohibited.
• B. Blood transfusions are forbidden.
• C. Alcohol use in any form is not allowed.
• D. A vegetarian diet must be followed.

Correct answer: B

Rationale: The correct answer is B: 'Blood transfusions are forbidden.' Jehovah's Witnesses typically refuse blood transfusions due to their religious beliefs. This is crucial for the LPN to consider when planning the client's care to ensure that alternative treatments are explored. Choices A, C, and D are incorrect as they do not align with the specific beliefs and practices of Jehovah's Witnesses. Autopsy prohibition, alcohol use restrictions, and dietary preferences are not primary concerns related to the religious beliefs of Jehovah's Witnesses.

3. During an IV catheter insertion demonstration, which statement by a nurse indicates understanding of the procedure?

• A. “I will thread the needle into the vein at an angle of 10 to 30 degrees with the bevel up.”
• B. “I will insert the needle into the client’s skin at an angle of 10 to 30 degrees with the bevel up.”
• C. “I will apply pressure approximately 1.2 inches below the insertion site before removing the needle.”
• D. “I will select a vein in the antecubital fossa for IV insertion based on its size and easily accessible location.”

Correct answer: B

Rationale: The correct technique for IV catheter insertion involves inserting the needle at a 10 to 30-degree angle with the bevel up. This angle facilitates proper vein puncture, reduces the risk of complications, and minimizes trauma to the vein. Choice A is incorrect because threading the needle into the vein at an angle of 10 to 30 degrees with the bevel up is the correct technique, not threading it all the way into the vein. Choice C is incorrect because applying pressure 1.2 inches below the insertion site before removing the needle is not a standard step in IV catheter insertion. Choice D is incorrect because selecting the antecubital fossa vein solely based on its size and accessibility may not be the most appropriate criterion; vein selection should also consider factors like vein condition and patient comfort.

4. When planning to insert a peripheral IV catheter for an older adult client, which of the following actions should the nurse plan to take?

• A. Insert the catheter at a 45° angle
• B. Place the client's arm in a dependent position
• C. Shave excess hair from the insertion site
• D. Initiate IV therapy in the veins of the hand

Correct answer: B

Rationale: Placing the client's arm in a dependent position is the correct action when inserting a peripheral IV catheter for an older adult client. This position helps veins dilate due to gravity, facilitating easier insertion of the IV catheter. Choice A is incorrect because catheters are typically inserted at a lower angle, around 10-30 degrees. Choice C is unnecessary unless excessive hair impedes the insertion process. Choice D is incorrect as veins in the hand are generally smaller and more prone to complications, making them less ideal for IV therapy in older adults.

5. Upon completing the admission documents, the nurse learns that the 87-year-old client does not have an advance directive. What action should the nurse take?

• A. Record the lack of advance directive on the chart
• B. Give information about advance directives
• C. Assume that the client wishes a full code
• D. Refer this issue to the unit secretary

Correct answer: B

Rationale: The correct action for the nurse to take is to give information about advance directives to the client. By providing this information, the nurse empowers the client to make an informed decision about their care preferences. Choice A is incorrect because simply recording the lack of advance directive does not address the client's need for information. Choice C is incorrect because assuming the client wishes a full code without discussing it with them is not appropriate and may not align with the client's wishes. Choice D is incorrect as the nurse should directly address the issue with the client rather than involving another staff member.

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