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. Following a recent tattoo, someone should be screened for:

• A. tuberculosis.
• B. herpes.
• C. hepatitis.
• D. syphilis.

Correct answer: C

Rationale: Following a recent tattoo, someone should be screened for hepatitis. Tattooing puts a client at risk for blood-borne hepatitis B or C if strict sterile procedures are not followed. Tuberculosis is an airborne pathogen, while herpes and syphilis are spread through direct contact like sexual activity. Therefore, hepatitis is the most relevant infection to screen for after getting a tattoo.

3. During surgery, it is found that a client with adenocarcinoma of the rectum has positive peritoneal lymph nodes. What is the next most likely site of metastasis?

• A. brain
• B. bone
• C. liver
• D. mediastinum

Correct answer: C

Rationale: In cases of adenocarcinoma of the rectum with positive peritoneal lymph nodes, the most likely site of metastasis is the liver. Colon tumors commonly spread through the lymphatics and portal vein to the liver. While metastasis to the brain, bone, or mediastinum is possible, the liver is typically the first to be affected due to the anatomical pathways involved in colorectal cancer metastasis. Therefore, the correct answer is the liver. Metastasis to the brain, bone, or mediastinum would be less likely at this stage of colorectal cancer progression.

4. A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except:

• A. the client reports no episodes of awakening during the night.
• B. the client falls asleep within 1 hour of going to bed.
• C. the client reports satisfaction with their amount of sleep.
• D. the client rates sleep as an 8 or more on the visual analog scale.

Correct answer: B

Rationale: An expected outcome for a nursing care plan targeting sleep problems is that the client reports no episodes of awakening during the night, the client reports satisfaction with their amount of sleep, and the client rates sleep as an 8 or more on the visual analog scale. Falling asleep within 1 hour of going to bed is not necessarily an expected outcome. While it is generally desirable for individuals to fall asleep within a reasonable time frame, this specific timeframe may vary among individuals, and it is not a strict criterion for successful sleep outcomes. Therefore, the correct answer is that the client falls asleep within 1 hour of going to bed, as this is not a definitive measure of the effectiveness of the nursing care plan for sleep problems.

5. When the healthcare provider is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client?

• A. corner of the mouth to tragus of the ear
• B. corner of the eye to top of the ear
• C. tip of the chin to the sternum
• D. tip of the nose to the earlobe

Correct answer: D

Rationale: A nasopharyngeal airway is measured from the tip of the nose to the earlobe. This measurement ensures that the airway is of the correct length to reach the nasopharynx without being too long or too short. Choices A, B, and C are incorrect as they do not provide the appropriate measurement for selecting the correct size of a nasopharyngeal airway. The distance from the corner of the mouth to the tragus of the ear (Choice A) is used to measure for an oropharyngeal airway, not a nasopharyngeal airway. Similarly, the other choices (B and C) do not correlate with the correct measurement of a nasopharyngeal airway.

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