Nursing Elites

1. What intervention is most important for the LPN/LVN to implement for a male client experiencing urinary retention?

• A. Apply a condom catheter.
• B. Apply a skin protectant.
• C. Encourage increased fluid intake.
• D. Assess for bladder distention.

Correct answer: D

Rationale: The most important intervention for the LPN/LVN to implement for a male client experiencing urinary retention is to assess for bladder distention. This assessment is crucial as it helps identify the underlying cause of urinary retention, such as bladder distention or obstruction. By assessing the bladder, the LPN/LVN can determine the appropriate interventions needed, such as catheterization, medication administration, or further evaluation by the healthcare provider. Applying a condom catheter (Choice A) is more suitable for urinary incontinence, not retention. Applying a skin protectant (Choice B) is typically done to prevent skin breakdown in incontinent clients. Encouraging increased fluid intake (Choice C) may be beneficial for some urinary issues but is not the priority intervention for urinary retention.

2. A nurse is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

• A. Use the complete name of the medication magnesium sulfate
• B. Maintain the space between the numerical dose and the unit of measure
• C. Note the dosage of insulin in units
• D. Use 'subcut' for indicating a subcutaneous injection

Correct answer: A

Rationale: The correct answer is A. The Institute for Safe Medication Practices recommends using the complete medication name magnesium sulfate when documenting medications to prevent misinterpretation. Choice B is incorrect because spaces should be maintained between the numerical dose and unit of measure for clarity. Choice C is incorrect as the standard notation for insulin dosage is in units, not using the letter U. Choice D is incorrect as the abbreviation for subcutaneous injection is commonly written as 'subcut' or 'subcutaneous,' not as SC.

3. During the physical assessment of a client, which technique should a nurse use when performing a Romberg's test?

• A. Touch the client's face with a cotton ball
• B. Apply a vibrating tuning fork to the client's forehead
• C. Have the client stand with arms at her sides and feet together
• D. Perform direct percussion over the area of the kidneys

Correct answer: C

Rationale: During a Romberg's test, the nurse assesses the client's balance. Having the client stand with arms at her sides and feet together is the correct technique. This position helps the nurse observe for swaying or loss of balance, indicating alterations in balance. Choices A and B are incorrect as they are not part of Romberg's test and do not assess balance. Choice D is also incorrect as direct percussion over the kidneys is not associated with a Romberg's test.

4. A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse’s priority?

• A. Teaching the client about the purpose of the medication
• B. Giving the medication at the administration time the provider prescribed
• C. Identifying the client’s medication allergies
• D. Documenting the client’s anxiety level

Correct answer: C

Rationale: The correct answer is C: Identifying the client's medication allergies. This is the priority action before administering any medication to prevent allergic reactions or adverse effects. Teaching the client about the medication's purpose is important for client understanding but not as critical as ensuring the absence of allergies. While giving medication at the prescribed time is crucial, verifying allergies takes precedence to ensure patient safety. Documenting the client's anxiety level is relevant for holistic care but is not the priority compared to ensuring safe medication administration.

5. The healthcare provider is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the healthcare provider recommend?

• A. High protein, high calorie
• B. High carbohydrate, low fat
• C. High vitamin A, high vitamin E
• D. Fluid restricted, bland

Correct answer: A

Rationale: The correct answer is A: High protein, high calorie. An immobilized patient with impaired skin integrity requires a diet high in protein and calories to repair injured tissue and rebuild depleted protein stores. This helps in promoting wound healing and preventing further breakdown of the skin. Choices B, C, and D are incorrect because while vitamins and minerals are essential for overall health, in this case, the priority is on providing sufficient protein and calories to support healing and recovery in an immobilized patient with impaired skin integrity.

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