Nursing Elites

1. A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client's history indicates a potential hazard for this test?

• A. Reflex incontinence
• B. Allergic to shellfish
• C. Claustrophobia
• D. Hypertension

Correct answer: B

Rationale: The correct answer is B, 'Allergic to shellfish.' An allergy to shellfish can indicate a sensitivity to iodine, which is used in the contrast dye for an IVP, posing a risk of an allergic reaction. Reflex incontinence (Choice A) is not directly related to the potential hazard of an IVP. Claustrophobia (Choice C) and hypertension (Choice D) are also not significant factors that indicate a potential hazard for an IVP.

2. How can the LPN/LVN best handle the situation of a postoperative client being kept awake by a neighboring client with dementia who sings all night?

• A. Tell the neighboring client to stop singing.
• B. Close the doors to both clients' rooms at night.
• C. Give the complaining client the prescribed sedative as needed.
• D. Move the neighboring client to a room at the end of the hall.

Correct answer: D

Rationale: The best way to handle the situation in this scenario is to move the neighboring client to a room at the end of the hall. This solution is considerate to both clients because it addresses the issue by providing a quieter environment for the client with dementia while allowing the postoperative client to rest. Choice A is inappropriate as it does not address the root cause of the problem and may not be feasible or respectful. Choice B of closing the doors may not effectively reduce the noise disturbance. Choice C of giving the complaining client sedatives should be the last resort and not the initial solution, as it does not address the underlying issue causing the disturbance.

3. A client requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

• A. Help the client take sips of water to promote insertion of the NG tube.
• B. Insert the tube without asking the client to swallow.
• C. Advance the tube continuously without pausing.
• D. Use a large-bore tube for insertion.

Correct answer: A

Rationale: The correct action when inserting an NG tube is to help the client take sips of water. This helps facilitate the insertion of the tube by promoting swallowing and passage through the esophagus. Asking the client to swallow assists in guiding the tube into the stomach. Inserting the tube without asking the client to swallow may lead to incorrect placement or discomfort. Advancing the tube continuously without pausing can cause the tube to coil in the esophagus, leading to complications. Using a large-bore tube for insertion is unnecessary and may increase the risk of injury or discomfort for the client.

4. The nurse is caring for a client with a central venous catheter. What is the most important action for the nurse to take to prevent infection?

• A. Change the catheter dressing every 72 hours.
• B. Flush the catheter with heparin solution daily.
• C. Ensure the catheter is clamped when not in use.
• D. Maintain sterile technique when handling the catheter.

Correct answer: D

Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. Changing the catheter dressing every 72 hours, while important for overall catheter care, does not directly address infection prevention. Flushing the catheter with heparin solution daily is essential for maintaining patency but does not primarily prevent infections. Ensuring the catheter is clamped when not in use is important for preventing air embolism but is not the most critical action to prevent infection. The most effective way to prevent infections is by strictly adhering to sterile techniques during catheter handling, which minimizes the risk of introducing pathogens into the catheter site.

5. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B: 'Glasgow Coma Scale 8, respirations regular.' A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deep state of unconsciousness, which may not be accurate in this case. Choice C is incorrect as stating the client 'appears to be sleeping' may not accurately reflect the severity of the situation. Choice D is incorrect because a Glasgow Coma Scale of 13 would not typically correspond to a non-responsive state.

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