Nursing Elites

1. To minimize the side effects of vincristine (Oncovin) that a client is receiving, what does the LPN/LVN expect the dietary plan to include?

• A. Low in fat
• B. High in iron
• C. High in fluids
• D. Low in residue

Correct answer: C

Rationale: The correct answer is to include a diet high in fluids to help minimize the side effects of vincristine. High fluid intake is important in managing potential side effects such as constipation, which is a common issue associated with vincristine therapy. Options A, B, and D are incorrect. A diet low in fat or high in iron is not specifically indicated for managing vincristine side effects. Additionally, a diet low in residue is not directly related to addressing vincristine side effects.

2. The nurse is caring for an older adult patient diagnosed with Alzheimer's disease who is ambulatory but requires total assistance with activities of daily living (ADLs). The nurse notices that the patient is edentulous. Which area should the nurse assess?

• A. Assess oral cavity.
• B. Assess room for drafts.
• C. Assess ankles for edema.
• D. Assess for reduced sensations.

Correct answer: A

Rationale: The correct answer is to assess the oral cavity. 'Edentulous' means without teeth, so the nurse should assess the oral cavity for any issues related to oral health, dentures, or potential complications. This assessment is crucial to prevent oral health problems and ensure proper care for the patient. Assessing the room for drafts (choice B) is unrelated to the patient's edentulous status and does not address the immediate care needs. Assessing ankles for edema (choice C) is important for circulatory assessment but not directly related to the patient being edentulous. Assessing for reduced sensations (choice D) would be more relevant for neurological or sensory concerns, which are not specifically associated with being edentulous.

3. Before administering the prescribed morphine sulfate to a client post-op following laparotomy who reports pain and dry mouth, what should the nurse do first?

• A. Measure the client's vital signs.
• B. Assess the client's pain level.
• C. Verify the morphine order with another nurse.
• D. Check the client's last dose of morphine.

Correct answer: A

Rationale: Before administering morphine sulfate, it is crucial to measure the client's vital signs to ensure that the client is stable and safe to receive the medication. This step helps identify any contraindications or abnormalities that could affect the administration of morphine. Assessing the client's pain level (choice B) is important, but ensuring the client's physiological stability takes precedence. Verifying the morphine order with another nurse (choice C) and checking the client's last dose of morphine (choice D) are important steps but are not the priority before administering the medication.

4. A client scheduled for a hysterectomy has not yet signed the operative consent form. When the nurse approaches the client and asks that she review and sign the form, the client says she no longer wants to have the surgery. At this time, which action should the nurse take?

• A. Ask the client why she has changed her mind
• B. Proceed with the surgery
• C. Notify the surgeon immediately
• D. Document the client’s decision

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to ask the client why she has changed her mind. By understanding the client's reasons for refusal, the nurse can address any concerns, provide further information, and ensure that the client's decision is respected. Proceeding with the surgery without clarifying the client's decision or notifying the surgeon immediately would not be appropriate. Documenting the client's decision is important, but it should be done after understanding the rationale behind the decision.

5. A healthcare professional is preparing to administer an opioid medication to a client for pain management. Which of the following actions should the healthcare professional take?

• A. Administer the medication as prescribed without any additional monitoring.
• B. Monitor the client for respiratory depression.
• C. Administer the medication only when the client requests it.
• D. Ask another healthcare professional to verify the medication before administration.

Correct answer: B

Rationale: When administering opioid medications, it is crucial to monitor the client for respiratory depression, which is a potential side effect of opioids. Monitoring for respiratory depression is a critical safety measure to ensure the client's well-being during opioid therapy. Option A is incorrect because additional monitoring, especially for respiratory depression, is necessary when giving opioids to prevent adverse effects. Option C is incorrect as administering the medication only upon client request may compromise effective pain management and adherence to the prescribed regimen. Option D is incorrect as medication verification by another healthcare professional is essential for safety but not directly related to monitoring the client for respiratory depression after opioid administration.

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