Nursing Elites

1. A client is admitted for evaluation and control of HTN. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse's first reaction at this time is to:

• A. Establish an airway
• B. Call for assistance
• C. Check the client's pulse and blood pressure
• D. Perform CPR

Correct answer: A

Rationale: In a situation where a client is found unresponsive on the floor, the nurse's first priority is to establish an airway. This is crucial to ensure that the client can breathe adequately and receive oxygen. Without a patent airway, the client's oxygenation and ventilation may be compromised, leading to serious consequences. Calling for assistance is important, but establishing an airway takes precedence as it directly impacts the client's ability to breathe. Checking the client's pulse and blood pressure can be done after ensuring a clear airway. Performing CPR is not the immediate action needed unless the client's breathing and pulse are absent after the airway has been secured.

2. A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take?

• A. Perform deep palpation at the end of the admission assessment
• B. Auscultate the client’s abdomen before palpation
• C. Begin palpation of the abdomen at the site of pain
• D. Assess the client’s bowel sounds using the bell of the stethoscope

Correct answer: B

Rationale: Auscultating the abdomen before palpation is the correct action for the nurse to take in this scenario. This approach helps to assess bowel sounds accurately and prevents the alteration of bowel sounds that can occur due to palpation. By auscultating first, the nurse can gather important information about bowel function before proceeding with the palpation. Choice A is incorrect because deep palpation should be avoided initially, especially in a client reporting abdominal pain, as it may cause discomfort or potential harm. Choice C is incorrect as palpation should typically start away from the site of pain to prevent exacerbating discomfort. Choice D is incorrect because assessing bowel sounds with the bell of the stethoscope is not the initial step recommended when a client reports abdominal pain; auscultation should be performed with the diaphragm of the stethoscope first.

3. The healthcare provider is preparing to administer a subcutaneous injection of heparin. Which site is most appropriate for the healthcare provider to use?

• A. Deltoid muscle
• B. Ventrogluteal site
• C. Abdomen
• D. Dorsogluteal site

Correct answer: C

Rationale: The abdomen is the most appropriate site for administering subcutaneous heparin injections. The abdomen has a layer of subcutaneous fat and a good blood supply, making it an ideal site for subcutaneous injections. Using the deltoid muscle for heparin injections is not appropriate as it is typically used for intramuscular injections. The ventrogluteal site is more suitable for intramuscular injections rather than subcutaneous injections. The dorsogluteal site is no longer recommended for injections due to the risk of injury to the sciatic nerve.

4. A client is talking with an older adult who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I’m not sure I want to retire.' Which of the following responses should the nurse make?

• A. Let’s talk about how the change in your job status will affect you.
• B. You should consider how retirement will affect your financial situation.
• C. Retirement is a big change, take your time to decide.
• D. Have you thought about what you will do after you retire?

Correct answer: A

Rationale: The correct response is to discuss how the change in job status will affect the client. This helps the client consider the emotional and psychological impact of retirement. Choice B focuses solely on the financial aspect of retirement, which may not address the client's current concerns about enjoying their job. Choice C acknowledges the decision-making process but does not actively engage the client in exploring their feelings. Choice D shifts the focus to post-retirement plans without addressing the client's current hesitation about retiring.

5. An unlicensed assistive personnel (UAP) places a client in a left lateral position before administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP?

• A. Position the client on the right side of the bed in reverse Trendelenburg.
• B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
• C. Reposition the client in a Sim's position with the weight on the anterior ilium.
• D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Correct answer: C

Rationale: The correct instruction the LPN/LVN should provide to the UAP is to reposition the client in a Sim's position with the weight on the anterior ilium for administering a soap suds enema. This position helps facilitate the administration of the enema by providing better access and comfort for the client. Choice A is incorrect as reverse Trendelenburg is not the appropriate position for administering a soap suds enema. Choice B is incorrect as the concentration of soap in the enema solution is not specified and might be too strong. Choice D is incorrect as raising the side rails and elevating the bed does not directly relate to the proper positioning for administering the enema.

Similar Questions