Nursing Elites

1. A client with a history of diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the LPN/LVN to take?

• A. Monitor the client's blood glucose level.
• B. Encourage the client to increase fluid intake.
• C. Administer insulin as prescribed.
• D. Assess the client's urine output.

Correct answer: A

Rationale: The most important action for the LPN/LVN to take when a client with a history of diabetes mellitus experiences symptoms of hyperglycemia such as polyuria, polydipsia, and polyphagia is to monitor the client's blood glucose level. This action helps assess the severity of hyperglycemia and guides further interventions. Encouraging the client to increase fluid intake (Choice B) may exacerbate the symptoms by further diluting the blood glucose concentration. Administering insulin as prescribed (Choice C) should be done based on the healthcare provider's orders and after assessing the blood glucose levels. Assessing the client's urine output (Choice D) is important but not the most immediate action needed in this scenario.

2. A client who is non-ambulatory 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. Evacuate the client
• B. Attempt to extinguish the fire
• C. Call the fire department
• D. Close the door to contain the fire

Correct answer: A

Rationale: The correct answer is to Evacuate the client (Choice A). In the event of a fire, the safety of the client is the top priority. The RACE (Rescue, Alarm, Contain, Extinguish) mnemonic is used in fire emergencies. The first step is to Rescue or Evacuate the individual from immediate danger. Attempting to extinguish the fire (Choice B) may endanger both the client and the nurse. Calling the fire department (Choice C) is important but should come after ensuring the client's safety. Closing the door to contain the fire (Choice D) is not appropriate in this scenario because the priority is to remove the client from harm's way.

3. The healthcare provider is planning care for a 14-year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan?

• A. Administer antibiotic therapy for 10 days
• B. Teach the client isometric exercises for legs
• C. Assess movement and sensation of extremities
• D. Assist the client to stand up at the bedside within the first 24 hours

Correct answer: C

Rationale: Assessing movement and sensation of extremities is the priority after scoliosis corrective surgery as it helps in early detection of any neurological deficits that may have occurred during the procedure. This assessment is essential for prompt intervention if any issues are identified. Administering antibiotics, teaching exercises, and assisting the client to stand up are important aspects of care but assessing neurological status takes precedence to ensure the client's safety and recovery.

4. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states, 'I demand to be released now!' The appropriate action is for the nurse to:

• A. You cannot be released because you are still suicidal.
• B. You can be released only if you sign a no-suicide contract.
• C. Let's discuss your decision to leave and then we can prepare you for discharge.
• D. You have a right to sign out as soon as we get an order from the healthcare provider's discharge order.

Correct answer: C

Rationale: The correct action for the nurse in this scenario is to engage the client in a discussion about their decision to leave and then prepare them for discharge. This approach allows the nurse to assess the client's current state, address concerns, and plan for a safe discharge. Option A is incorrect because it does not involve a therapeutic communication approach and may escalate the situation. Option B is incorrect as it places a condition on the client for release, which is not recommended in this situation. Option D is incorrect as it does not prioritize the client's autonomy and right to make decisions about their care.

5. The patient diagnosed with athlete's foot (tinea pedis) states that he is relieved because it is only athlete's foot, and it can be treated easily. Which information about this condition should the nurse consider when formulating a response to the patient?

• A. It is contagious with frequent recurrences.
• B. It is most helpful to air-dry feet after bathing.
• C. It is treated with salicylic acid.
• D. It is caused by lice.

Correct answer: A

Rationale: Athlete's foot, also known as tinea pedis, is a contagious fungal infection that can easily spread to other body parts, particularly the hands. It often recurs if not properly treated, making choice A the correct answer. Choices B and C are incorrect because while it is beneficial to air-dry feet after bathing to prevent moisture buildup, athlete's foot is commonly treated with antifungal medications, not salicylic acid. Choice D is incorrect because athlete's foot is caused by a fungal infection, not lice.

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