Nursing Elites

1. A client is admitted with a diagnosis of septicemia. Which assessment finding should the LPN/LVN report to the healthcare provider immediately?

• A. Increased urine output
• B. Decreased blood pressure
• C. Increased heart rate
• D. Increased respiratory rate

Correct answer: B

Rationale: In a client with septicemia, decreased blood pressure is a critical finding that suggests potential septic shock, a life-threatening condition. Septic shock requires immediate medical intervention to prevent further deterioration and organ dysfunction. Increased urine output (Choice A) may indicate adequate fluid resuscitation, which is a positive response. Increased heart rate (Choice C) and increased respiratory rate (Choice D) are common physiological responses to sepsis and do not necessarily indicate immediate life-threatening complications like decreased blood pressure does in septic shock.

2. A client is being taught about medications at discharge. Which statement should the nurse identify as an indication that the client understands the instructions?

• A. I can open the time-release capsule with the beads in it and sprinkle them on my oatmeal.
• B. If I am having difficulty swallowing, I will add the liquid medication to a prepared package of pudding.
• C. I can crush the enteric-coated pill if needed.
• D. I will eat two crackers with the pain pills.

Correct answer: B

Rationale: The correct answer is B. Adding liquid medication to pudding can help with swallowing difficulties, demonstrating understanding of the instructions. Options A and C are incorrect as altering time-release capsules and enteric-coated pills is not recommended in medication administration. Option A is incorrect as time-release capsules should not be opened and sprinkled on food, affecting their efficacy. Option C is incorrect as crushing enteric-coated pills can affect their absorption. Option D is unrelated to medication administration and does not demonstrate understanding of the instructions.

3. A client is receiving discharge instructions for using a walker. Which statement indicates an understanding of the teaching?

• A. I will hire someone to trim the tree that hangs low over the stairs of my front porch.
• B. I will avoid using the walker on uneven surfaces.
• C. I will use the walker on stairs for added support.
• D. I will not need to make any changes to my home environment.

Correct answer: A

Rationale: The correct answer is A because hiring someone to trim low-hanging branches over stairs ensures home safety and reflects an understanding of walker use. This action indicates the client's awareness of potential hazards and the importance of a safe environment for walker use. Choice B is incorrect as avoiding uneven surfaces is a general safety precaution but does not directly relate to walker use and does not demonstrate an understanding of the teaching. Choice C is incorrect because using a walker on stairs is not recommended due to safety concerns such as balance and fall risks. Choice D is incorrect as making no changes to the home environment may pose safety risks when using a walker, showing a lack of understanding regarding safety precautions needed for walker use.

4. A client requires a 24-hour urine collection. Which statement by the client indicates an understanding of the teaching?

• A. "I had a bowel movement, but I was able to save the urine."
• B. "I have a specimen in the bathroom from about 30 minutes ago."
• C. "I flushed what I urinated at 7 a.m. and have saved all urine since."
• D. "I drink a lot, so I will fill up the bottle and complete the test quickly."

Correct answer: C

Rationale: The correct answer is C because for a 24-hour urine collection, the first void is discarded, and all subsequent urine should be saved. Choice A is incorrect because bowel movements do not contribute to a urine collection. Choice B indicates a single specimen rather than continuous collection over 24 hours. Choice D is incorrect as it incorrectly suggests rushing the test by drinking excessively.

5. A healthcare professional is reviewing a client's fluid and electrolyte status. Which of the following findings should the healthcare professional report to the provider?

• A. BUN 15 mg/dL
• B. Creatinine 0.8 mg/dL
• C. Sodium 143 mEq/L
• D. Potassium 5.4 mEq/L

Correct answer: D

Rationale: The correct answer is D. A potassium level of 5.4 mEq/L is above the expected reference range, indicating hyperkalemia. Hyperkalemia can lead to serious complications such as dysrhythmias, making it important for the healthcare professional to report this finding to the provider for further evaluation and intervention. Choices A, B, and C fall within normal ranges and do not pose an immediate risk to the client's health, so they would not warrant immediate reporting to the provider. Elevated BUN or creatinine levels may indicate kidney dysfunction, while a sodium level of 143 mEq/L falls within the normal range for adults and does not typically require urgent intervention.

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