Nursing Elites

1. A client in the emergency department is being cared for by a nurse and has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

• A. Tachycardia
• B. Elevated blood pressure
• C. Warm, dry skin
• D. Decreased respiratory rate

Correct answer: A

Rationale: Tachycardia is a hallmark sign of hypovolemic shock. When a client experiences significant blood loss, the body compensates by increasing the heart rate to maintain adequate perfusion to vital organs. Elevated blood pressure is not typically seen in hypovolemic shock; instead, hypotension is a more common finding. Warm, dry skin is characteristic of neurogenic shock, not hypovolemic shock. Decreased respiratory rate is not a typical manifestation of hypovolemic shock, as the body usually tries to increase respiratory effort to improve oxygenation in response to hypovolemia.

2. A client who is 5'5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the LPN to include during the preoperative assessment?

• A. What is your daily calorie consumption?
• B. What vitamin and mineral supplements do you take?
• C. Do you feel that you are overweight?
• D. Will a clear liquid diet be okay after surgery?

Correct answer: B

Rationale: During the preoperative assessment, it is crucial for the LPN to inquire about the client's intake of vitamin and mineral supplements. This is important because certain supplements can have effects on coagulation, wound healing, and overall surgical outcomes. Asking about daily calorie consumption (Choice A) is not as pertinent as inquiring about vitamin and mineral supplements in this context. Questioning the client about feeling overweight (Choice C) may not directly impact the surgical outcome compared to the effects of supplements. Inquiring about the post-surgery diet (Choice D) is relevant but not as critical as understanding the client's supplement intake.

3. A healthcare professional is admitting a client who has decreased circulation in his left leg. Which of the following actions should the healthcare professional take first?

• A. Evaluate pedal pulses
• B. Assess skin temperature
• C. Check for capillary refill
• D. Measure the leg circumference

Correct answer: A

Rationale: Evaluating pedal pulses should be the first action taken as it provides immediate information about circulation. This assessment helps in determining the adequacy of blood flow in the client's leg. Assessing skin temperature, checking for capillary refill, and measuring leg circumference are important assessments; however, evaluating pedal pulses is the most crucial initial step in this scenario. Skin temperature assessment and capillary refill check can provide additional valuable information about perfusion, while measuring leg circumference is useful in monitoring for edema. Therefore, for a client with decreased circulation in the left leg, evaluating pedal pulses takes precedence over the other assessments.

4. The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area?

• A. Neck, shoulders, and chest
• B. Abdomen and groin/perineum
• C. Legs, feet, and web spaces
• D. Back of neck, back, and then buttocks

Correct answer: B

Rationale: In providing a complete bed bath using a bag bath for an unconscious patient, the nurse should follow a specific order. The correct sequence is as follows: Neck, shoulders, and chest; Both arms, both hands, web spaces, and axilla; Abdomen and then groin/perineum; Right leg, right foot, and web spaces; Left leg, left foot, and web spaces; Back of neck, back, and then buttocks. Choice A is incorrect as it does not follow the correct sequence for a bed bath. Choice C is incorrect as it focuses on the lower extremities before addressing the upper body. Choice D is incorrect as it starts with the back of the patient instead of the upper body areas first.

5. A client with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client is short of breath and has a pulse oximetry reading of 88%. What action should the LPN take first?

• A. Increase the oxygen flow rate to 4 liters per minute.
• B. Reposition the client to a high Fowler's position.
• C. Notify the healthcare provider of the client's condition.
• D. Encourage the client to use pursed-lip breathing.

Correct answer: B

Rationale: Repositioning the client to a high Fowler's position should be the first action taken by the LPN. This position helps improve oxygenation by maximizing lung expansion, making it easier for the client to breathe. Increasing the oxygen flow rate without addressing positioning may not fully optimize oxygen delivery. Notifying the healthcare provider should come after immediate interventions. Encouraging pursed-lip breathing is beneficial but should follow the initial positioning to further assist the client in managing their breathing difficulty.

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