Nursing Elites

1. A client is receiving 0.9% sodium chloride IV at 125 mL/hr. The nurse notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?

• A. Reposition the client
• B. Document the client's IV intake in the medical record
• C. Request a new IV fluid prescription
• D. Check the IV tubing for obstruction

Correct answer: D

Rationale: The correct answer is to check the IV tubing for obstruction. The first step in the nursing process is assessment. By checking the IV tubing for obstruction, the nurse can assess and potentially correct any issues affecting the flow rate. This action may help to ensure that the prescribed infusion rate is maintained. Repositioning the client is not the priority at this stage as the issue seems related to the IV tubing. Documenting the intake or requesting a new prescription are not immediate actions needed to address the current situation with the IV fluid flow.

2. During an initial history and physical assessment of a 3-month-old brought into the clinic for spitting up and excessive gas, what would the nurse expect to find?

• A. Increased temperature and lethargy
• B. Restlessness and increased mucus production
• C. Increased sleeping and listlessness
• D. Diarrhea and poor skin turgor

Correct answer: B

Rationale: Restlessness and increased mucus production are common signs of gastrointestinal issues or reflux in infants, which could explain the symptoms of spitting up and excessive gas. Increased temperature and lethargy (Choice A) are more indicative of an infection rather than gastrointestinal issues. Increased sleeping and listlessness (Choice C) are not typical signs associated with the symptoms described. Diarrhea and poor skin turgor (Choice D) are not directly related to the symptoms of spitting up and gas in this scenario.

3. The nurse is preparing to assist a newly admitted client with personal hygiene measures. The nurse wants to assess the client's gag reflex. Which action should the nurse include?

• A. Offer small sips of water through a straw
• B. Place tongue blade on back half of tongue
• C. Use a penlight to observe back of the oral cavity
• D. Auscultate breath sounds after the client swallows

Correct answer: B

Rationale: The correct action for the nurse to include when assessing the client's gag reflex is to place a tongue blade on the back half of the tongue. This method effectively tests the gag reflex without causing discomfort. Choice A is incorrect because offering small sips of water through a straw does not assess the gag reflex. Choice C is incorrect as using a penlight to observe the back of the oral cavity does not directly assess the gag reflex. Choice D is incorrect since auscultating breath sounds after the client swallows does not evaluate the gag reflex.

4. During a skin assessment, a healthcare professional is observing a group of clients. Which of the following lesions should the healthcare professional identify as vesicles?

• A. Acne
• B. Warts
• C. Psoriasis
• D. Herpes simplex

Correct answer: D

Rationale: Vesicles are small fluid-filled blisters. Herpes simplex is an example of a vesicular lesion, characterized by small, fluid-filled blisters. Acne presents as comedones, papules, pustules, or nodules, not vesicles. Warts are caused by the human papillomavirus and appear as rough, raised growths. Psoriasis is a chronic autoimmune condition that results in red, scaly patches on the skin, not vesicles.

5. The nurse is caring for a client with cirrhosis of the liver. Which finding should the LPN/LVN report to the healthcare provider immediately?

• A. Yellowing of the skin and eyes
• B. Dark-colored urine
• C. Abdominal distention
• D. Confusion

Correct answer: A

Rationale: Yellowing of the skin and eyes (jaundice) is a classic sign of liver dysfunction in clients with cirrhosis. Jaundice indicates the accumulation of bilirubin in the body due to impaired liver function. This finding suggests worsening liver damage and should be reported immediately to the healthcare provider for prompt evaluation and management. Dark-colored urine (choice B) is also a concerning symptom in liver disease, indicating possible bilirubin presence, but it is not as urgent as jaundice. Abdominal distention (choice C) and confusion (choice D) are common in cirrhosis but do not indicate an immediate need for healthcare provider notification compared to jajsondice.

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