Nursing Elites

1. A client with a history of chronic renal failure is admitted with generalized edema. Which laboratory value should the LPN/LVN monitor to assess the client's fluid balance?

• A. Serum potassium
• B. Serum calcium
• C. Serum albumin
• D. Serum sodium

Correct answer: C

Rationale: The correct answer is C, Serum albumin. In clients with chronic renal failure and generalized edema, monitoring serum albumin levels is crucial as it is a key indicator of fluid balance. Low serum albumin levels can contribute to edema formation due to decreased oncotic pressure, indicating fluid imbalance. Serum potassium (Choice A) is more related to kidney function and electrolyte balance in renal failure patients. Serum calcium (Choice B) is important for bone health but is not directly related to fluid balance. Serum sodium (Choice D) is more indicative of hydration status and electrolyte balance but may not directly reflect fluid balance in the context of chronic renal failure and edema.

2. The LPN is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer's disease. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen, the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication?

• A. Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care.
• B. Develop a chart for the client, listing the times the medication should be taken.
• C. Contact the primary health care provider and discuss the possibility of simplifying the medication regimen.
• D. Instruct the client and client's children to put medications in a weekly pill organizer.

Correct answer: C

Rationale: The priority nursing intervention in this scenario is to contact the primary health care provider and discuss the possibility of simplifying the medication regimen. Simplifying the medication regimen is crucial for a client with early Alzheimer's disease to ensure they can manage their medications independently and safely. This intervention focuses on optimizing the client's ability to adhere to the prescribed medication schedule. Choices A and D involve external assistance and may not address the core issue of simplifying the regimen. Choice B, while helpful, does not directly address the need to simplify the regimen to enhance the client's medication management.

3. While auscultating a client's abdomen, a nurse hears a blowing sound over the aorta. The nurse should identify this sound as which of the following?

• A. Gallop
• B. Bruit
• C. Thrill
• D. Murmur

Correct answer: B

Rationale: The correct answer is B: Bruit. A bruit is a blowing sound indicating turbulent blood flow, often heard over the aorta. Choices A, C, and D are incorrect. A gallop is a cardiac sound resembling the sound of a galloping horse. A thrill is a vibration felt on palpation, and a murmur is a swooshing or whooshing sound heard during auscultation of the heart or blood vessels. In this scenario, the blowing sound over the aorta specifically indicates a bruit, which signifies turbulent blood flow and should be further assessed by the healthcare provider.

4. The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area?

• A. Roof of mouth, gums, and inside cheeks
• B. Chewing and inner tooth surfaces
• C. Outer tooth surfaces
• D. Tongue

Correct answer: C

Rationale: The correct sequence for oral care is to clean the outer tooth surfaces first, followed by cleaning the inner tooth surfaces, then the roof of the mouth, gums, and inside cheeks with a toothette. Brushing the tongue should be the final step in the oral care procedure. Therefore, option C is the correct choice. Options A, B, and D are incorrect because they do not follow the correct order for providing oral care to a patient.

5. An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care?

• A. Irrigate the affected area with running water.
• B. Wash the affected area with antibacterial soap.
• C. Brush the chemical off the skin and clothing.
• D. Leave the clothing in place until emergency personnel arrive.

Correct answer: C

Rationale: The correct intervention for an employee exposed to an unknown dry chemical is to brush off the chemical from the skin and clothing. This helps prevent further skin contact before irrigation can be done. Irrigating the affected area with running water is crucial after brushing off the chemical to minimize the exposure. Washing the affected area with antibacterial soap is not appropriate for chemical burns, as soap can react with certain chemicals and worsen the situation. Leaving the clothing in place until emergency personnel arrive may allow the chemical to continue to harm the skin and should be avoided.

Similar Questions