Nursing Elites

1. When ambulating a frail, older adult client, the nurse should:

• A. Use the transfer belt if the client is unsteady
• B. Walk beside the client without support
• C. Encourage the client to use a walker
• D. Hold the client's arm for support

Correct answer: A

Rationale: Using a transfer belt if the client is unsteady is essential to provide added safety and support during ambulation. This device helps the nurse assist the client in maintaining balance and prevents falls. Walking beside the client without support (choice B) may not offer enough assistance for a frail, older adult who is unsteady. Encouraging the client to use a walker (choice C) could be helpful in some cases, but if the client is unsteady during ambulation, additional support like a transfer belt is more appropriate. Holding the client's arm for support (choice D) may not provide enough stability and safety compared to using a transfer belt.

2. A client with a history of hypertension is prescribed a low-sodium diet. Which food should the LPN/LVN recommend the client avoid?

• A. Fresh fruits
• B. Grilled chicken
• C. Whole grain bread
• D. Canned soup

Correct answer: D

Rationale: The correct answer is D, canned soup. Canned soups are often high in sodium content, which can be harmful to individuals with hypertension following a low-sodium diet. Fresh fruits, grilled chicken, and whole grain bread are generally healthier options with lower sodium content and can be included in a low-sodium diet. Fresh fruits provide essential vitamins and minerals, grilled chicken is a lean protein source, and whole grain bread offers fiber and nutrients without excessive sodium levels. Avoiding canned soup aligns with the goal of reducing sodium intake to manage hypertension.

3. During an admission history assessment, a client informs the nurse about consuming herbal tea every afternoon at work to alleviate stress. What ingredient is likely present in the tea?

• A. Chamomile
• B. Ginseng
• C. Ginger
• D. Echinacea

Correct answer: A

Rationale: The correct answer is A: Chamomile. Chamomile tea is commonly used for stress relief. Choice B, Ginseng, is not typically used in teas for stress relief but for energy and immune system support. Choice C, Ginger, is more commonly used for digestive health and nausea. Choice D, Echinacea, is often used to boost the immune system. Therefore, in the context of stress relief, Chamomile is the most appropriate ingredient.

4. A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include?

• A. Carbon monoxide does not have a distinct odor.
• B. Water heaters should be inspected every 5 years.
• C. The lungs are not damaged from carbon monoxide inhalation.
• D. Carbon monoxide binds with hemoglobin in the body.

Correct answer: D

Rationale: The correct answer is D: 'Carbon monoxide binds with hemoglobin in the body.' Carbon monoxide is an odorless, colorless gas, so it does not have a distinct odor (Choice A). While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning (Choice B). Carbon monoxide primarily affects the cardiovascular system by binding with hemoglobin, reducing the blood's ability to carry oxygen, rather than causing direct lung damage (Choice C). Understanding how carbon monoxide binds with hemoglobin is crucial in recognizing the mechanism of poisoning and its potential consequences.

5. While being prepared for transport to the operating room, a client scheduled for hysterectomy informs the nurse that she no longer wants to have surgery. What action should the nurse take?

• A. Notify the provider about the client's decision
• B. Proceed with the transport
• C. Prepare the surgical site
• D. Document the client’s statement

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to notify the provider about the client's decision. By informing the provider, they can discuss the client's change in decision, explore the reasons behind it, and determine the appropriate course of action. Proceeding with the transport (Choice B) without addressing the client's concerns would not respect the client's autonomy and right to make decisions about their own healthcare. Preparing the surgical site (Choice C) would be premature and inappropriate if the client no longer wishes to proceed with the surgery. While documenting the client's statement (Choice D) is important for documentation purposes, the immediate priority is to involve the provider in the decision-making process.

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