Nursing Elites

1. A client with a diagnosis of 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. 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 deeper state of unconsciousness than what is described in the scenario. Choice C is inaccurate as the client is not merely sleeping but non-responsive. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than what is presented in the scenario.

2. What action should the LPN/LVN take to prevent postoperative complications in a client who has undergone abdominal surgery?

• A. Encourage the client to use an incentive spirometer regularly.
• B. Assist the client in ambulating as soon as possible.
• C. Position the client in high Fowler's position.
• D. Encourage the client to cough and deep breathe regularly.

Correct answer: A

Rationale: Encouraging the client to use an incentive spirometer regularly is crucial in preventing postoperative complications after abdominal surgery. This action helps prevent atelectasis by promoting lung expansion and improving air exchange in the lungs, reducing the risk of respiratory complications. Assisting the client in ambulating early is important for preventing issues like deep vein thrombosis but may not directly address respiratory concerns postoperatively. Positioning the client in high Fowler's position can help with respiratory distress but is not as specific to preventing postoperative respiratory complications as using an incentive spirometer. While encouraging the client to cough and deep breathe is generally beneficial for lung expansion, using an incentive spirometer is more effective and targeted in preventing atelectasis after abdominal surgery.

3. In a client with liver cirrhosis, which symptom would be most concerning during assessment?

• A. Jaundice
• B. Ascites
• C. Hepatomegaly
• D. Altered mental status

Correct answer: D

Rationale: Altered mental status would be the most concerning symptom in a client with liver cirrhosis. It may indicate hepatic encephalopathy, a serious complication requiring immediate intervention. While jaundice, ascites, and hepatomegaly are common in liver cirrhosis, they do not directly correlate with the urgency and severity of hepatic encephalopathy as altered mental status does. Therefore, altered mental status takes priority for immediate attention and intervention.

4. In an emergency situation, the charge nurse on the night shift at an urgent care center has to deal with admitting clients of higher acuity than usual due to a large fire in the area. Which style of leadership and decision-making would be best in this circumstance?

• A. Assume a decision-making role
• B. Seek input from staff
• C. Use a non-directive approach
• D. Shared decision-making with others

Correct answer: A

Rationale: In an emergency situation such as dealing with patients of higher acuity due to a large fire, it is crucial for the charge nurse to assume a decision-making role. This style of leadership allows for quick and efficient decision-making to manage the increased acuity of patients effectively. Seeking input from staff (Choice B) may delay critical decisions needed in emergencies. Using a non-directive approach (Choice C) or shared decision-making with others (Choice D) may not be suitable in urgent situations where immediate actions are required to address the high acuity of patients.

5. Which statement by the nurse indicates culturally responsive care for a client following Islamic practices?

• A. “I will make sure the menu includes halal options.”
• B. “I will ask the client if they want to schedule prayer times during the day.”
• C. “I will avoid discussing care when the client’s family is around.”
• D. “I will make sure daily communion is available for this client.”

Correct answer: B

Rationale: The correct answer is B. Asking the client if they want to schedule prayer times during the day demonstrates respect and consideration for Islamic practices. Providing halal options (choice A) is important for dietary requirements in Islam, but it may not address the client's spiritual needs. Avoiding discussing care in front of the client's family (choice C) is not directly linked to Islamic practices and may not necessarily enhance cultural responsiveness. Offering daily communion (choice D) is associated with Christian religious practices, not Islamic practices, and may not meet the client's religious needs.

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