Nursing Elites

1. Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage?

• A. Insert an indwelling urinary catheter.
• B. Limit caloric and protein intake.
• C. Turn the patient every 2 hours.
• D. Assess for pain during a bath.

Correct answer: D

Rationale: The most important action for preventing skin impairment in a mobile patient with local nerve damage is to assess for pain during a bath. Assessing pain during a bath helps in evaluating sensory nerve function by checking for touch, pain, heat, cold, and pressure. This assessment is crucial in identifying areas of potential skin breakdown and implementing preventive measures. Inserting an indwelling urinary catheter (Choice A) is not directly related to preventing skin impairment in this context. Limiting caloric and protein intake (Choice B) is not pertinent to skin impairment prevention for a mobile patient with local nerve damage. While turning the patient every 2 hours (Choice C) is a good practice for preventing pressure ulcers, in this case, assessing for pain during a bath is more directly related to preventing skin impairment associated with nerve damage.

2. The patient diagnosed with athlete's foot (tinea pedis) states that he is relieved because it is only athlete's foot, and it can be treated easily. Which information about this condition should the nurse consider when formulating a response to the patient?

• A. It is contagious with frequent recurrences.
• B. It is most helpful to air-dry feet after bathing.
• C. It is treated with salicylic acid.
• D. It is caused by lice.

Correct answer: A

Rationale: Athlete's foot, also known as tinea pedis, is a contagious fungal infection that can easily spread to other body parts, particularly the hands. It often recurs if not properly treated, making choice A the correct answer. Choices B and C are incorrect because while it is beneficial to air-dry feet after bathing to prevent moisture buildup, athlete's foot is commonly treated with antifungal medications, not salicylic acid. Choice D is incorrect because athlete's foot is caused by a fungal infection, not lice.

3. The LPN is caring for a client who has been placed in restraints. What is the most important action for the nurse to take?

• A. Ensure that the client’s circulation is checked every hour.
• B. Document the reason for the restraints every 4 hours.
• C. Provide range-of-motion exercises every 2 hours.
• D. Release the restraints every 2 hours for repositioning.

Correct answer: D

Rationale: The most crucial action for the nurse to take when caring for a client in restraints is to release the restraints every 2 hours for repositioning. This practice helps prevent complications such as pressure ulcers and impaired circulation by ensuring adequate blood flow and preventing skin breakdown. Checking the client's circulation every hour (Choice A) is important, but releasing the restraints for repositioning takes precedence to prevent serious complications. While documenting the reason for restraints (Choice B) is essential for legal and documentation purposes, it is not as critical as providing necessary care to the client's physical well-being. Providing range-of-motion exercises (Choice C) is beneficial for maintaining mobility but may not address the immediate risks associated with prolonged restraint use.

4. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?

• A. Why don’t we now have the client turn back to the left side.
• B. That was done correctly. Did you have any problems with the insertion?
• C. Let’s check to see if the suppository is in far enough.
• D. Did you feel any stool in the intestinal tract?

Correct answer: B

Rationale: The appropriate comment by the nurse is to affirm the correct technique while offering support and checking for any issues during the insertion.

5. A nurse is talking with caregivers of a 12-year-old child. Which of the following issues verbalized by the caregivers should the nurse identify as the priority?

• A. “We just don’t understand why our child can’t keep up with the other kids in simple activities like running and jumping.”
• B. “Our child keeps trying to find ways around our household rules. They always want to make deals with us.”
• C. “We think our child is trying too hard to excel in math just to get the top grades in the class.”
• D. “Our child likes to sing and worries it will make the other kids want to laugh.”

Correct answer: A

Rationale: The correct answer is A. Difficulty in keeping up with physical activities like running and jumping may indicate an underlying physical or developmental issue that requires prompt assessment. This could be related to musculoskeletal problems, coordination difficulties, or other health concerns that need further evaluation. Choices B, C, and D, while important, do not address a potential physical or developmental issue that could impact the child's overall well-being. Addressing the child's physical limitations should be the priority to ensure appropriate support and intervention.

Similar Questions