Nursing Elites

1. A client is 6 hours postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?

• A. Allow the client to hear running water while attempting to void
• B. Provide the client with a bedpan while sitting upright
• C. Insert an indwelling urinary catheter and connect it to gravity drainage
• D. Encourage the client to limit fluid intake

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to allow the client to hear running water while attempting to void. This can help stimulate the urge to urinate in a non-invasive way, promoting natural voiding. Providing a bedpan while sitting upright is also a suitable approach to facilitate voiding by encouraging a more natural position. Inserting an indwelling urinary catheter should be a last resort due to infection risks and discomfort associated with catheterization. Encouraging the client to limit fluid intake is not appropriate as hydration is crucial for overall health and can aid in promoting voiding. Therefore, the best initial intervention to promote voiding in this scenario is to allow the client to hear running water.

2. The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the LPN/LVN administer?

• A. 0.5 ml
• B. 1 ml
• C. 1.5 ml
• D. 2 ml

Correct answer: A

Rationale: To administer 4 mg of morphine, as prescribed, the LPN/LVN needs to calculate the correct volume based on the concentration provided (8 mg per ml). Since the desired dose is 4 mg, half of 8 mg (0.5 ml) is required to administer the correct amount. Therefore, the correct answer is 0.5 ml. Choices B, C, and D are incorrect as they would either underdose or overdose the patient.

3. The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the LPN that this client understands the dietary restrictions?

• A. Tossed salad with low-sodium dressing, bacon, and tomato sandwich.
• B. New England clam chowder, unsalted crackers, fresh fruit salad.
• C. Skim milk, turkey salad, roll, and vanilla ice cream.
• D. Macaroni and cheese, diet Coke, and a slice of cherry pie.

Correct answer: C

Rationale: The correct answer is C: Skim milk, turkey salad, roll, and vanilla ice cream. These items are low in sodium, making it a suitable meal for someone on a low-sodium diet. Skim milk, turkey salad, and vanilla ice cream are naturally low in sodium, while the roll can be selected as a low-sodium option. Choices A, B, and D contain items that are typically high in sodium, such as bacon, clam chowder, crackers, and cheese, making them unsuitable for a low-sodium diet.

4. After repositioning a client who reports shortness of breath, which of the following actions should the nurse take next?

• A. Observe the rate, depth, and character of the client's respirations.
• B. Take the client’s blood pressure.
• C. Assess the client's pulse.
• D. Offer supplemental oxygen.

Correct answer: A

Rationale: Observing the rate, depth, and character of the client's respirations is crucial after repositioning a client experiencing shortness of breath. This action provides immediate information about the client's respiratory status. Checking blood pressure (Choice B) is not the priority in this situation, as assessing respirations is more urgent. Assessing the pulse (Choice C) is also important but does not provide direct information about the client's respiratory status. Offering supplemental oxygen (Choice D) may be necessary based on the assessment of respirations, but it should not be the first action taken without assessing the client's breathing pattern.

5. The client is being discharged and has been prescribed furosemide (Lasix). Which statement by the client indicates an understanding of the medication?

• A. I will take this medication on an empty stomach for optimal absorption.
• B. I will weigh myself daily and report any significant weight loss.
• C. I will include potassium-rich foods in my diet while taking this medication.
• D. I will take this medication in the morning to prevent nocturia.

Correct answer: B

Rationale: The correct answer is B. Weighing daily and reporting significant weight loss is crucial when taking furosemide to monitor for potential fluid and electrolyte imbalances. Choice A is incorrect because furosemide is typically taken on an empty stomach for optimal absorption. Choice C is incorrect as furosemide can lead to potassium loss, so potassium-rich foods should be consumed. Choice D is incorrect because furosemide is usually taken earlier in the day to prevent nocturia, not at bedtime.

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