Nursing Elites

1. A client requires bed rest and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take?

• A. Apply the stockings with the creases on the front of the leg.
• B. Apply the stockings while the client's legs are in a dependent position.
• C. Remove the stockings at least once per shift.
• D. Remove the stockings while the client is sitting in a reclining chair.

Correct answer: C

Rationale: The correct action for the nurse to take is to remove the anti-embolic stockings at least once per shift. This is essential to assess the client's circulation and skin integrity. Option A is incorrect because the stockings should be applied without creases to ensure proper compression. Option B is incorrect as the stockings should be applied when the client's legs are elevated, not in a dependent position. Option D is incorrect as removing the stockings while the client is sitting in a reclining chair is not necessary and does not provide the appropriate assessment opportunity.

2. A child is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

• A. Administer analgesics to the child on a routine schedule throughout the day and night.
• B. Offer fluids to the child immediately after surgery.
• C. Allow the child to return to solid foods gradually.
• D. Avoid administering any medication until the child is fully awake.

Correct answer: A

Rationale: Administering analgesics to the child on a routine schedule throughout the day and night is crucial for managing postoperative pain effectively and ensuring the child's comfort. Pain management is a priority in the postoperative period to promote healing and prevent complications. Offering fluids to the child immediately after surgery (Choice B) is essential to prevent dehydration, but pain control takes precedence. Allowing the child to return to solid foods gradually (Choice C) is important, but initially, the child may need to start with clear liquids and progress to soft foods post-tonsillectomy. Avoiding administering any medication until the child is fully awake (Choice D) is not advisable because timely pain relief is essential for the child's comfort and recovery.

3. A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?

• A. A client who has new onset of dyspnea 24 hours after a total hip arthroplasty
• B. A client who has acute abdominal pain rated 4 on a scale from 0 to 10
• C. A client who has a UTI and low-grade fever
• D. A client who has pneumonia and an oxygen saturation of 96%

Correct answer: A

Rationale: The nurse should see the client who has new onset of dyspnea 24 hours after a total hip arthroplasty first. New onset of dyspnea, especially after surgery, can indicate a serious complication such as a pulmonary embolism or deep vein thrombosis. It is essential to assess this client promptly to rule out potentially life-threatening conditions. Acute abdominal pain, a UTI with low-grade fever, and pneumonia with an oxygen saturation of 96% are important issues but do not indicate the urgency and potential severity of a post-operative complication like pulmonary embolism or deep vein thrombosis.

4. During a client admission, how should the nurse conduct medication reconciliation?

• A. Compare the client’s home medications to the provider's prescriptions.
• B. Review the client’s medical history.
• C. Assess the client's current medications.
• D. Ask the client about their allergies.

Correct answer: A

Rationale: During medication reconciliation, the nurse should compare the client’s home medications with the provider's prescriptions to ensure accuracy and prevent medication errors. Reviewing the client’s medical history (Choice B) is important but not the primary focus of medication reconciliation. Assessing the client's current medications (Choice C) is also vital but is not specific to the comparison between home and prescribed medications during reconciliation. Asking the client about their allergies (Choice D) is relevant for ensuring safe medication administration but is not the primary step in medication reconciliation, which involves comparing actual medications.

5. A client with type 1 diabetes mellitus is experiencing hypoglycemia. What is the best initial action for the LPN/LVN to take?

• A. Administer glucagon intramuscularly.
• B. Give the client 4 ounces of orange juice.
• C. Give the client a snack containing protein and carbohydrates.
• D. Encourage the client to rest until symptoms resolve.

Correct answer: B

Rationale: The best initial action for a client with type 1 diabetes mellitus experiencing hypoglycemia is to give them 4 ounces of orange juice. Orange juice quickly raises blood glucose levels in a hypoglycemic client. Administering glucagon intramuscularly is not the best initial action for hypoglycemia; it is usually reserved for severe hypoglycemia cases. Giving a snack containing protein and carbohydrates is not as rapid as orange juice in raising blood glucose levels during hypoglycemia. Encouraging the client to rest until symptoms resolve does not address the immediate need to raise blood glucose levels in a hypoglycemic state.

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