Nursing Elites

1. The PN observes a UAP bathing a bedfast client with the bed in the high position. Which action should the PN take?

• A. Remain in the room to supervise the UAP
• B. Determine if the UAP would like assistance
• C. Assume care of the client immediately
• D. Instruct the UAP to lower the bed for safety

Correct answer: D

Rationale: The correct action for the PN to take in this situation is to instruct the UAP to lower the bed for safety. Keeping the bed in the lowest position during care activities is crucial for preventing falls and injuries to both the client and the caregiver. Instructing the UAP to lower the bed addresses the immediate safety concern. Choice A is incorrect because simply supervising the UAP without addressing the unsafe bed height does not ensure the client's safety. Choice B is incorrect as the priority is to address the safety concern rather than offering assistance to the UAP. Choice C is incorrect as assuming care of the client immediately does not address the root issue of the high bed position.

2. At 1200, the practical nurse learns that a client's 0900 dose of an anticonvulsant was not given. The next scheduled dose is at 2100. Which action should the PN take?

• A. Administer half of the missed dose immediately
• B. Administer the missed dose as soon as possible
• C. Give the missed dose with the next scheduled dose
• D. Withhold the missed dose unless seizure activity occurs

Correct answer: B

Rationale: Administering the missed dose as soon as possible is crucial in this situation. Missing an anticonvulsant dose can lead to breakthrough seizures, which are harmful to the client. Administering the missed dose promptly helps maintain the therapeutic level of the medication and reduces the risk of seizure activity. Giving half the dose may not provide adequate protection against seizures. Delaying the dose until the next scheduled time increases the time the client is without the medication, potentially increasing the risk of seizures. Withholding the missed dose unless seizure activity occurs is not recommended, as prevention is key in managing anticonvulsant therapy.

3. When preparing to administer a medication through a nasogastric (NG) tube, what is the first action the nurse should take?

• A. Check the placement of the NG tube
• B. Flush the tube with saline
• C. Position the client in a semi-Fowler's position
• D. Administer the medication slowly

Correct answer: A

Rationale: The correct first action when preparing to administer a medication through a nasogastric (NG) tube is to check the placement of the NG tube. This step is essential to ensure that the tube is correctly positioned in the stomach and not in the lungs, preventing potential complications. Flushing the tube with saline may be required, but it should follow the verification of tube placement. Positioning the client in a semi-Fowler's position is necessary for comfort during the procedure but is not the initial step. Administering the medication can only be done safely after confirming the correct placement of the NG tube.

4. A female client who has been taking oral contraceptives for the past year comes to the clinic for an annual exam. Which finding is most important for the PN to report to the HCP?

• A. Breast tenderness
• B. Change in menstrual flow
• C. Left calf pain
• D. Weight gain of 5 pounds

Correct answer: C

Rationale: Left calf pain could indicate deep vein thrombosis (DVT), a serious side effect of oral contraceptives. Reporting this finding to the healthcare provider is critical for further evaluation and treatment. Breast tenderness and change in menstrual flow are common side effects of oral contraceptives and may not be as urgent as left calf pain. Weight gain of 5 pounds, while noteworthy, is not as concerning as a possible indication of DVT.

5. Inspiratory and expiratory stridor may be heard in a client who:

• A. Is experiencing an exacerbation of goiter
• B. Is experiencing an acute asthmatic attack
• C. Has aspirated a piece of meat
• D. Has severe laryngotracheitis

Correct answer: D

Rationale: Inspiratory and expiratory stridor are high-pitched, wheezing sounds caused by disrupted airflow due to airway obstruction. Severe laryngotracheitis, involving inflammation and swelling of the larynx and trachea, leads to airway obstruction and can produce both inspiratory and expiratory stridor. Exacerbation of goiter, an acute asthmatic attack, and aspiration of a piece of meat are not typically associated with both inspiratory and expiratory stridor. Therefore, choices A, B, and C are incorrect.

Similar Questions