Nursing Elites

1. A healthcare professional is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the healthcare professional take?

• A. Place the bladder of the cuff over the posterior aspect of the thigh
• B. Use a smaller cuff designed for lower extremities
• C. Place the cuff around the client's ankle
• D. Ensure the cuff is positioned above the knee

Correct answer: A

Rationale: When measuring blood pressure in the lower extremity, the bladder of the cuff should be placed over the posterior aspect of the thigh. This positioning ensures an accurate measurement. Placing the cuff around the ankle (Choice C) or above the knee (Choice D) would not provide an accurate blood pressure reading in the lower extremity. Using a smaller cuff designed for lower extremities (Choice B) is not appropriate as the standard cuff size should be used with the bladder placed over the posterior aspect of the thigh.

2. A client is on bed rest following an abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes?

• A. Flat rash on the client's ankle
• B. Non-blanching red area over the client's trochanter
• C. Ecchymosis on the client's left shoulder
• D. Petechiae on the client's right anterior thigh

Correct answer: B

Rationale: The presence of a non-blanching red area over the client's trochanter is a concerning finding as it indicates possible pressure ulcer formation. This finding necessitates an increase in the frequency of position changes to prevent skin breakdown. Choices A, C, and D do not directly correlate with the need for increased position changes. A flat rash, ecchymosis, and petechiae may have different causes and would not be addressed by changing the client's position more frequently.

3. The nurse is preparing to administer a medication through a nasogastric (NG) tube. Which action should the LPN/LVN take to ensure proper administration?

• A. Check the placement of the tube by auscultation.
• B. Flush the tube with 30 ml of water before and after medication administration.
• C. Administer the medication with food to prevent nausea.
• D. Dilute the medication with normal saline before administration.

Correct answer: B

Rationale: To ensure proper administration through a nasogastric tube, the LPN/LVN should flush the tube with 30 ml of water before and after medication administration. This action helps ensure the tube is patent, prevents clogging, and helps deliver the medication effectively. Checking the placement of the tube by auscultation (Choice A) is essential but does not directly relate to ensuring proper administration. Administering the medication with food (Choice C) may not always be appropriate for all medications and may not necessarily prevent nausea. Diluting the medication with normal saline (Choice D) is not a standard practice for all medications administered via an NG tube and may alter the medication's effectiveness.

4. The nurse is assessing a client who has just been admitted with a diagnosis of acute pancreatitis. Which finding is most important for the LPN/LVN to report to the healthcare provider immediately?

• A. Elevated serum lipase level
• B. Severe abdominal pain
• C. Nausea and vomiting
• D. Hypotension

Correct answer: D

Rationale: Hypotension is a critical finding that should be reported immediately in a client with acute pancreatitis as it may indicate severe complications such as hemorrhage or shock. While elevated serum lipase level, severe abdominal pain, and nausea/vomiting are common manifestations of acute pancreatitis, hypotension is a more urgent sign requiring immediate attention to prevent further deterioration. Hypotension can be a sign of significant fluid loss, hemorrhage, or sepsis, which are potentially life-threatening conditions that need prompt intervention. Elevated serum lipase levels, severe abdominal pain, and nausea/vomiting are important in the assessment of pancreatitis but do not indicate the same level of immediate danger as hypotension does.

5. A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy?

• A. Collaborating with providers to perform obesity screenings during routine office visits.
• B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity.
• C. Providing specialized intraoperative training in surgical treatments for obesity.
• D. Educating acute care nurses about postoperative complications related to obesity.

Correct answer: A

Rationale: The correct answer is A: Collaborating with providers to perform obesity screenings during routine office visits. This is a primary health care strategy as it focuses on prevention and early detection, which are key components of managing obesity. Screening during routine visits allows for timely identification of obesity and related health risks, enabling early intervention. Choices B, C, and D do not align with primary health care strategies for obesity. Ensuring availability of specialized beds, providing intraoperative training, and educating about postoperative complications are more focused on secondary and tertiary levels of care, rather than primary prevention and early detection.

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