Nursing Elites

1. After abdominal surgery, a client has not urinated since the urinary catheter was removed 8 hours ago. What action should the LPN take first?

• A. Perform a bladder scan to assess for urinary retention.
• B. Encourage the client to drink fluids.
• C. Insert a straight catheter to drain the bladder.
• D. Administer a diuretic as prescribed.

Correct answer: A

Rationale: Performing a bladder scan is the initial step to assess for urinary retention in a postoperative client. This non-invasive technique helps determine the volume of urine in the bladder, guiding further interventions. Encouraging the client to drink fluids (Choice B) may be beneficial but is not the priority when assessing for urinary retention. Inserting a straight catheter (Choice C) should not be the initial action without first assessing for retention. Administering a diuretic (Choice D) should not be done without confirming the need through assessment.

2. The nurse is assessing a client with a diagnosis of pheochromocytoma. Which symptom should the nurse expect to find?

• A. Hypertension
• B. Bradycardia
• C. Hypoglycemia
• D. Weight gain

Correct answer: A

Rationale: The correct answer is A: Hypertension. Pheochromocytoma is characterized by the overproduction of catecholamines, leading to symptoms such as hypertension. Bradycardia (Choice B) is not typical in pheochromocytoma as increased catecholamines usually lead to tachycardia. Hypoglycemia (Choice C) and weight gain (Choice D) are not commonly associated symptoms of pheochromocytoma.

3. A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?

• A. Bend at the knees while maintaining a wide stance and a straight back, with the client’s hands on the nurse’s shoulders, and the nurse’s hands under the client’s axillae
• B. Use a mechanical lift
• C. Twist at the waist while holding the client
• D. Ask for assistance from another staff member

Correct answer: A

Rationale: The correct technique for transferring a client from a bed to a chair to avoid back injuries is to bend at the knees while maintaining a wide stance and a straight back. This position ensures that the nurse uses leg muscles rather than the back muscles for lifting, reducing the risk of injury. Placing the client’s hands on the nurse’s shoulders and the nurse’s hands under the client’s axillae provides additional support and stability during the transfer. Using a mechanical lift may be appropriate for certain situations but is not necessary for a simple bed-to-chair transfer. Twisting at the waist while holding the client can lead to back strain or injury. Asking for assistance from another staff member is a good practice, but proper body mechanics should still be followed to ensure safe client handling.

4. 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.

5. A client asks a nurse about their Snellen eye test results. The client's visual acuity is 20/30. Which of the following responses should the nurse make?

• A. “Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.”
• B. “Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet.”
• C. “Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet.”
• D. “Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet.”

Correct answer: A

Rationale: The correct answer is A: 'Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.' In the Snellen eye test, a visual acuity of 20/30 means that the client sees at 20 feet what a person with normal vision sees at 30 feet. This indicates that the client's vision is slightly worse than average. Choice B is incorrect as it incorrectly describes the visual acuity of each eye individually, rather than the combined visual acuity. Choice C is incorrect as it misinterprets the meaning of the Snellen eye test results by reversing the values. Choice D is incorrect as it inaccurately describes the visual acuity of the client's eyes, attributing different visual acuities to each eye instead of a combined measurement as indicated by 20/30.

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