Nursing Elites

1. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102°F), heart rate of 105/min, a soft tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse’s priority?

• A. Temperature
• B. Menses overdue
• C. Soft tender abdomen
• D. Heart rate

Correct answer: A

Rationale: The correct answer is A: Temperature. A high temperature of 39.2°C (102°F) indicates a fever, which can be a sign of infection or another serious condition. Investigating the cause of the fever is a priority to address any underlying health issue promptly. Menses overdue (choice B) could be relevant but is not as urgent as addressing a fever. A soft tender abdomen (choice C) is important but may be a consequence of the underlying condition causing the fever. Heart rate (choice D) is also significant, but the priority here is to identify the cause of the fever.

2. During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventive strategies?

• A. “I will leave the IV catheter in place after the client completes the course of IV antibiotics.”
• B. “As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt.”
• C. “If my client needs to use the restroom, it would be safer to disconnect their IV infusion as long as I clean the injection port thoroughly with an antiseptic swab.”
• D. “I will replace any IV catheter when I suspect contamination during insertion.”

Correct answer: D

Rationale: The correct answer is D: “I will replace any IV catheter when I suspect contamination during insertion.” This statement demonstrates an understanding of preventive strategies for IV infections. Suspecting and replacing any contaminated IV catheter during insertion is crucial to prevent infections and ensure patient safety. Choices A, B, and C are incorrect because leaving the IV catheter in place after completing antibiotics, reusing the same IV catheter, and disconnecting the IV infusion without proper precautions can increase the risk of infections. Therefore, option D is the best choice for preventing IV infections.

3. A client with a history of congestive heart failure (CHF) is admitted with dyspnea and a productive cough. What is the most important assessment for the LPN/LVN to perform?

• A. Measure the client's urine output.
• B. Auscultate the client's lung sounds.
• C. Assess the client's apical pulse.
• D. Check the client's blood pressure.

Correct answer: B

Rationale: Auscultating lung sounds is crucial for assessing the extent of congestion in a client with CHF. The presence of crackles or wheezing can indicate fluid accumulation in the lungs, a common complication of CHF. Monitoring urine output (Choice A) is important to assess renal function but is not the priority in this situation. While assessing the apical pulse (Choice C) and checking blood pressure (Choice D) are important in managing CHF, they do not provide immediate information about the respiratory status and congestion level in the lungs, making auscultating lung sounds the most critical assessment.

4. A client is scheduled for hip surgery in an hour. Which of the following actions is the nurse’s priority?

• A. Ensure that the client signs the consent form.
• B. Lock the client’s valuables in a secure location.
• C. Verify the client’s lab values in the medical record.
• D. Administer the prescribed preoperative sedative.

Correct answer: A

Rationale: The nurse’s priority is to ensure that the client signs the consent form before the hip surgery. This is crucial as it ensures that the client has provided informed consent for the procedure. Locking valuables, verifying lab values, and administering sedatives are important tasks but ensuring consent takes precedence as it directly impacts the client’s right to make decisions about their care.

5. A client is admitted with a diagnosis of left-sided heart failure. Which assessment finding would be most concerning?

• A. Peripheral edema
• B. Crackles in the lungs
• C. Jugular vein distention
• D. Hepatomegaly

Correct answer: B

Rationale: The correct answer is B: Crackles in the lungs. Crackles in the lungs indicate pulmonary congestion, a serious complication of left-sided heart failure. The presence of crackles suggests fluid accumulation in the lungs, impairing gas exchange and potentially leading to respiratory distress. Immediate intervention is necessary to prevent worsening respiratory function. Choices A, C, and D are incorrect: Peripheral edema is a common finding in heart failure but may not be as acutely concerning as pulmonary congestion. Jugular vein distention is associated with right-sided heart failure, not left-sided heart failure. Hepatomegaly is often seen in liver conditions and right-sided heart failure, not specifically left-sided heart failure.

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