Nursing Elites

1. During an admission assessment, a healthcare professional finds a client's radial pulse rate to be 68/min and the simultaneous apical pulse to be 84/min. What is the client’s pulse deficit (per minute)?

• A. 16
• B. 12
• C. 6
• D. 14

Correct answer: A

Rationale: The pulse deficit is calculated by finding the difference between the apical and radial pulse rates. In this case, the difference is 84 - 68 = 16. This indicates that there is a pulse deficit of 16 beats per minute. Choices B, C, and D are incorrect as they do not accurately reflect the difference between the two pulse rates.

2. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse?

• A. Reassure the client that he will become accustomed to the stoma's appearance in time.
• B. Instruct the client that the stoma will become smaller when the initial swelling diminishes.
• C. Offer to contact a member of the local ostomy support group to help him with his concerns.
• D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

Correct answer: B

Rationale: The correct response is to instruct the client that the stoma will become smaller when the initial swelling diminishes. This explanation helps reassure the client about the temporary appearance of the stoma. Choice A is incorrect because simply reassuring the client that he will become accustomed to the stoma's appearance does not address the immediate concern about the stoma size. Choice C is incorrect because offering to contact a support group does not directly address the client's current distress about the stoma size. Choice D is incorrect because encouraging the client to handle stoma equipment does not directly address the client's concern about the stoma size and may not be appropriate at this time.

3. A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dL. What is the priority nursing action for the LPN/LVN?

• A. Administer insulin as prescribed.
• B. Administer oral hypoglycemic agents.
• C. Monitor blood glucose levels frequently.
• D. Provide a high-calorie diet.

Correct answer: A

Rationale: The correct answer is to administer insulin as prescribed. When a client with diabetes mellitus presents with a critically high blood glucose level like 600 mg/dL, the priority action is to lower the blood glucose level promptly to prevent complications. Insulin is the appropriate medication to rapidly reduce high blood glucose levels. Administering oral hypoglycemic agents may not act quickly enough in this critical situation. While monitoring blood glucose levels frequently is important, immediate intervention to lower the high blood glucose level takes precedence. Providing a high-calorie diet is contraindicated in this scenario as it would further elevate the blood glucose level.

4. A nurse in a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which concept should the nurse and client discuss in the termination phase of the relationship?

• A. Loss
• B. Autonomy
• C. Confidentiality
• D. Accountability

Correct answer: A

Rationale: In the termination phase of a nurse-client relationship, discussing 'loss' is crucial to help the client understand and process the end of the therapeutic relationship and any emotional impact. This discussion can aid in closure and transitioning out of the professional relationship. 'Autonomy' refers to the client's right to make decisions about their care, which is important throughout the relationship but not specifically in the termination phase. 'Confidentiality' is essential for maintaining trust but is not the primary focus during termination. 'Accountability' involves being answerable for one's actions, which is important in nursing practice but not a central topic in the termination phase of the relationship.

5. The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

• A. Remove the needle after discarding used syringes
• B. Wear gloves while disposing of the needle and syringe
• C. Wear a face mask during medication administration
• D. Wash hands before handling the needle and syringe

Correct answer: D

Rationale: The correct answer is D. Washing hands before handling the needle and syringe is a critical step in infection control and adherence to standard precautions. Clean hands help prevent the transfer of microorganisms and reduce the risk of infection. Choices A, B, and C do not directly relate to standard precautions. Removing the needle after discarding used syringes (Choice A) can increase the risk of needlestick injuries. Wearing gloves while disposing of the needle and syringe (Choice B) is important for personal protection but does not specifically address standard precautions. Wearing a face mask during medication administration (Choice C) is not directly related to handling syringes and needles, which are more pertinent to standard precautions.

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