Nursing Elites

1. How should the LPN document pain for a non-verbal client using the FLACC pain scale with these findings?

• A. 1
• B. 4
• C. 3
• D. 2

Correct answer: B

Rationale: The correct answer is B: '4'. The FLACC pain scale assesses pain in non-verbal patients based on five categories: Face, Legs, Activity, Cry, and Consolability. In this case, the client exhibits occasional grimacing (1 point), relaxed legs (0 points), squirming (1 point), moans and whimpers (1 point), and is distractible (1 point). Adding these points together results in a total pain score of 4. Therefore, the LPN should document a pain score of 4 for this non-verbal client. Choices A, C, and D are incorrect as they do not accurately reflect the total pain score based on the given findings.

2. Delegation of tasks to appropriate personnel allows the nurse to:

• A. ensure tasks are appropriately distributed.
• B. keep other members of the team productive.
• C. maintain tight control of all aspects of the workflow.
• D. recognize the importance of team members' roles.

Correct answer: B

Rationale: Delegating tasks to appropriate personnel is essential for a nurse to keep other team members productive. By assigning tasks that align with the specific roles and responsibilities of team members, the nurse can enhance work effectiveness and efficiency. Option A is incorrect because delegation is not primarily about ensuring tasks are evenly distributed but rather about utilizing team members' skills effectively. Option C is incorrect as maintaining tight control of all aspects of the workflow can hinder teamwork and limit individual growth. Option D is incorrect because effective delegation involves empowering team members to make decisions within their scope of practice, rather than solely recognizing the importance of their roles.

3. A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first?

• A. Asking the client to wiggle their toes
• B. Medicating the client with the prescribed analgesic
• C. Realigning the client
• D. Removing some of the traction weights

Correct answer: C

Rationale: When a client in skeletal traction complains of pain, the priority action for the nurse is to realign the client. Severe pain may indicate the need for realignment or that the traction weights are too heavy. Realigning the client should be the initial response as it can help alleviate the pain by ensuring proper alignment. Asking the client to wiggle their toes may not address the underlying issue causing the pain. Removing traction weights should never be done unless specifically ordered by the healthcare provider as it can affect the traction's effectiveness. Medicating the client with analgesics should only be considered after attempting to address the cause of the pain, which in this case, is realignment.

4. A client with dumping syndrome should ___________ while a client with GERD should ___________.

• A. lie down 1 hour after meals; sit up at least 30 minutes after meals
• B. sit up 1 hour after meals; lie flat 30 minutes after meals
• C. sit up after meals; sit up after meals
• D. lie down after meals; lie down after meals

Correct answer: A

Rationale: Clients with dumping syndrome should lie down after eating to decrease the symptoms of dumping syndrome, which include rapid gastric emptying leading to various gastrointestinal symptoms. On the other hand, clients with GERD should sit up at least 30 minutes after meals to prevent the backflow of stomach acid into the esophagus. This position helps reduce symptoms by allowing gravity to keep the stomach contents in place, minimizing the chances of reflux. Therefore, the correct answer is to lie down 1 hour after eating for dumping syndrome and to sit up at least 30 minutes after eating for GERD. Choices B, C, and D are incorrect because they do not accurately reflect the appropriate positioning for each condition.

5. A nurse is assisting with data collection of a client who has sustained circumferential burns of both legs. What should the nurse examine first?

• A. Heart rate
• B. Peripheral pulses
• C. Blood pressure (BP)
• D. Radial pulse rate

Correct answer: B

Rationale: The priority assessment for a client with circumferential burns to the legs is to examine peripheral pulses. This is essential to ensure adequate circulation to the extremities. Circumferential burns can lead to compartment syndrome, causing decreased circulation to the affected limbs. Checking peripheral pulses is crucial to monitor for any signs of compromised circulation. While heart rate and blood pressure are important assessments in general, in the context of circumferential burns, the immediate concern is the risk of impaired circulation to the extremities. Therefore, assessing peripheral pulses takes precedence in this situation.

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