Nursing Elites

1. A client with a history of asthma is experiencing shortness of breath. What is the most appropriate action for the LPN/LVN to take first?

• A. Administer a bronchodilator as prescribed.
• B. Encourage the client to practice deep breathing exercises.
• C. Position the client in high Fowler's position.
• D. Obtain a peak flow reading.

Correct answer: A

Rationale: Administering a bronchodilator as prescribed is the most appropriate initial action for managing asthma-related shortness of breath. Bronchodilators help to open up the airways quickly, providing relief for the client. Encouraging deep breathing exercises may be beneficial in some situations but should not be the first action for acute shortness of breath in asthma. Positioning the client in high Fowler's position can also help improve breathing, but administering the bronchodilator takes precedence. Obtaining a peak flow reading is important in asthma management, but it is not the initial action needed to address acute shortness of breath.

2. A healthcare professional is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The professional should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

• A. 107 mL/hr
• B. 120 mL/hr
• C. 95 mL/hr
• D. 100 mL/hr

Correct answer: A

Rationale: To calculate the infusion rate, divide the total volume (750 mL) by the total time (7 hr). 750 ÷ 7 ≈ 107 mL/hr. Choice A is correct because it accurately calculates the infusion rate based on the total volume and time. Choices B, C, and D are incorrect as they do not reflect the correct calculation for the infusion rate in this scenario.

3. A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?

• A. A report of 10 pounds weight loss in the last month
• B. A comment by the client 'I just can't sit still.'
• C. The appearance of eyeballs that appear to 'pop' out of the client's eye sockets
• D. A report of the sudden onset of irritability in the past 2 weeks

Correct answer: C

Rationale: The appearance of eyeballs that appear to 'pop' out of the client's eye sockets, known as exophthalmos, requires quick intervention as it is a severe symptom of Graves' disease. Exophthalmos can indicate an acute condition and may lead to serious complications such as optic nerve damage or corneal ulceration. Weight loss, restlessness, and irritability are common manifestations of hyperthyroidism but do not pose immediate risks compared to the ocular complications associated with exophthalmos.

4. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing?

• A. Assault
• B. Battery
• C. False imprisonment
• D. Invasion of privacy

Correct answer: A

Rationale: The correct answer is A: Assault. Assault involves making threats or using actions that cause the client to fear harm. In this scenario, the AP's threat to use diapers next time the urinal is used improperly constitutes as assault. Choice B, Battery, involves intentional harmful or offensive touching without consent, which is not evident in the scenario. Choice C, False imprisonment, refers to restraining or restricting a client's freedom of movement, which is not occurring in this situation. Choice D, Invasion of privacy, involves violating a client's right to privacy, which is also not applicable here.

5. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

• A. Activate the emergency fire alarm
• B. Extinguish the fire
• C. Evacuate the client
• D. Confine the fire

Correct answer: C

Rationale: The correct action for the nurse to take next, after confirming the fire, is to evacuate the client. In a fire situation, following the RACE mnemonic, the priority is to rescue or evacuate clients to ensure their safety. Activating the emergency fire alarm (Choice A) is important to alert others and the fire department, but evacuating the client takes precedence. Extinguishing the fire (Choice B) may put the nurse and client at risk and is best left to trained personnel. Confining the fire (Choice D) is not the nurse's responsibility; the focus should be on ensuring the client's safety by evacuating them.

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