Nursing Elites

1. A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients?

• A. Members of the same religion may have varying feelings about their religion.
• B. A shared religion background does not guarantee identical beliefs.
• C. The same religious beliefs can influence individuals differently.
• D. Discussing differences and commonalities in beliefs may not always be relevant.

Correct answer: C

Rationale: The correct answer is C. Religious beliefs can vary widely even among individuals of the same faith. It is essential for the nurse to recognize that the impact and interpretation of religious beliefs can differ from person to person. Choice A is incorrect as individuals within the same religion can have diverse feelings and interpretations. Choice B is incorrect because a shared religious background does not necessarily mean that individuals hold the same beliefs. Choice D is not the best course of action as discussing differences and commonalities in beliefs may not always be necessary or appropriate for providing care.

2. 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.

3. A client is admitted with a diagnosis of Guillain-Barre syndrome. Which assessment finding is most concerning?

• A. Loss of reflexes in the legs
• B. Decreased peripheral sensation
• C. Respiratory distress
• D. Muscle weakness in the arms

Correct answer: C

Rationale: The correct answer is C: Respiratory distress. In Guillain-Barre syndrome, respiratory distress is the most concerning finding as it can indicate progression to respiratory failure, which is a life-threatening complication. Loss of reflexes in the legs and muscle weakness in the arms are common manifestations of the condition but may not be as immediately life-threatening as respiratory distress. Decreased peripheral sensation is also a common symptom but is not as critical as respiratory distress in terms of immediate patient safety and management.

4. A client is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

• A. Monitor the client for pain in the suprapubic region.
• B. Ensure the client is free of metal objects.
• C. Administer 240 mL (8 oz) of oral contrast before the procedure.
• D. Assist the client with a bowel cleansing.

Correct answer: B

Rationale: The correct action for the nurse to include before an intravenous pyelogram is ensuring the client is free of metal objects. Metal objects can interfere with the imaging procedure and may need to be removed to prevent artifacts. Monitoring for pain in the suprapubic region (choice A) is not directly related to the procedure and is not a standard pre-procedure action. Administering oral contrast (choice C) is more common for other imaging studies like a CT scan, not an intravenous pyelogram. Assisting with a bowel cleansing (choice D) is not typically required before an intravenous pyelogram.

5. A PN is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would need no further intervention by the charge nurse?

• A. Telfa dressing with antibiotic ointment
• B. Moist sterile non-adherent dressing
• C. Dry sterile dressing that is occlusive
• D. Sterile occlusive pressure dressing

Correct answer: B

Rationale: The correct answer is B: Moist sterile non-adherent dressing. A moist sterile non-adherent dressing is suitable for covering a neural tube defect and would not require further intervention. This type of dressing helps prevent the dressing from sticking to the wound, minimizing trauma during dressing changes. Choice A, Telfa dressing with antibiotic ointment, is not ideal for a neural tube defect as the ointment may not be necessary and can complicate wound care. Choice C, dry sterile dressing that is occlusive, is not recommended for a neural tube defect as it may not provide the necessary environment for proper wound healing. Choice D, sterile occlusive pressure dressing, is excessive for a neural tube defect and may cause unnecessary pressure on the wound site.

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