Nursing Elites

1. During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the LPN/LVN implement?

• A. Provide additional coffee on the client's breakfast tray.
• B. Exchange the client's grape juice for cranberry juice.
• C. Bring the client additional fruit at mid-morning.
• D. Encourage additional oral intake of juices and water.

Correct answer: D

Rationale: Encouraging additional oral intake of juices and water is the appropriate intervention in this scenario. Dark amber urine can indicate concentrated urine due to dehydration or other factors. By encouraging more fluids, the LPN/LVN can help dilute the urine, reducing the concentration of pigments causing the dark color. Providing additional coffee (Choice A) would not necessarily increase hydration and could potentially have a diuretic effect. Exchanging grape juice for cranberry juice (Choice B) does not address the core issue of hydration. Bringing additional fruit (Choice C) may provide some fluid, but encouraging specific fluids like juices and water would be more effective in diluting the urine.

2. A healthcare professional is caring for a group of clients on a medical-surgical unit. Which of the following clients is at increased risk for body-image disturbances?

• A. A client who had a laparoscopic appendectomy
• B. A client who had a mastectomy
• C. A client who had a left above-the-knee amputation
• D. A client who had a cardiac catheterization

Correct answer: C

Rationale: Clients who have undergone significant visible body changes, like amputation, are at increased risk for body-image disturbances. Amputation can have a profound impact on self-image and body perception due to the visible structural alteration. While conditions like laparoscopic appendectomy, mastectomy, and cardiac catheterization may also affect body image, they are less likely to cause significant disturbances compared to visible changes like amputation.

3. When caring for an older adult client who becomes agitated when asked to remove dentures before surgery, which of the following responses should the nurse make?

• A. "What worries you about being without your teeth?"
• B. "You need to follow the preoperative instructions and remove your dentures."
• C. "It's important to remove dentures to ensure proper fitting of the mask during anesthesia."
• D. "I will explain why dentures need to be removed before surgery."

Correct answer: A

Rationale: The correct response is to ask the client about their concerns regarding being without their teeth. This approach helps address the client's anxiety and provides insight into the reason for their agitation. Choice B is authoritarian and does not address the client's emotional needs. Choice C focuses on the technical aspect of surgery and does not address the client's emotional state. Choice D implies a one-way communication without addressing the client's feelings or concerns.

4. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. Which device will the nurse use?

• A. Hand rolls
• B. A foot cradle
• C. A trapeze bar
• D. A trochanter roll

Correct answer: B

Rationale: A foot cradle is the correct choice for this situation. A foot cradle is used to reduce pressure on the tips of a patient's toes in individuals with poor lower extremity circulation. Hand rolls are not designed to address toe irritation specifically. A trapeze bar is used to assist patients with repositioning in bed, and a trochanter roll is used to support the hips and prevent external rotation of the legs, neither of which directly address toe irritation in this scenario.

5. A client with a terminal illness and approaching death has noisy respirations and is short of breath. Which of the following actions should the nurse take?

• A. Elevate the head of the client's bed
• B. Administer an opioid medication
• C. Perform oral suctioning
• D. Place the client in a prone position

Correct answer: A

Rationale: Elevating the head of the client's bed is the most appropriate action in this situation. It helps reduce noisy respirations and improves comfort for clients with terminal illnesses by facilitating better air exchange. Administering an opioid medication may not address the immediate issue of noisy respirations and shortness of breath caused by secretions in the airway. Performing oral suctioning without proper assessment and indication can be uncomfortable for the client and may not be necessary. Placing the client in a prone position can further compromise breathing and is not recommended for a client with respiratory distress.

Similar Questions