Nursing Elites

1. A nurse is caring for a postoperative client following knee arthroplasty who requires thigh-high compression sleeves. What should the nurse do?

• A. Make sure two fingers can fit under the sleeve.
• B. Apply the sleeve tightly to prevent blood clots.
• C. Ensure the sleeve is snug and comfortable.
• D. Check that the sleeve is loose enough to avoid constriction.

Correct answer: A

Rationale: The correct answer is to make sure two fingers can fit under the sleeve. This allows for proper circulation and ensures that the sleeve is not too tight, which can lead to complications such as impaired blood flow or tissue damage. Choice B is incorrect because applying the sleeve tightly can actually cause harm rather than prevent blood clots. Choice C is incorrect as snugness alone may not guarantee proper fit. Choice D is incorrect as a sleeve that is too loose can be ineffective in providing the necessary compression.

2. When is a depressed client at highest risk for attempting suicide?

• A. Immediately after admission, during one-to-one observation
• B. 7 to 14 days after initiation of antidepressant medication and psychotherapy
• C. Following an angry outburst with family
• D. When the client is removed from the security room

Correct answer: B

Rationale: Depressed clients are at the highest risk of attempting suicide 7 to 14 days after starting antidepressant medication and psychotherapy. During this time, they may start to regain energy but still feel hopeless, which can increase the risk of suicidal ideation and behavior. Choices A, C, and D are incorrect because immediate post-admission, after an angry outburst with family, or when removed from a security room are not specific periods known to be associated with the highest risk of suicide in depressed clients.

3. 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.

4. During auscultation of the anterior chest wall of a client newly admitted to a medical-surgical unit, what type of breath sounds should a nurse expect to hear?

• A. Normal breath sounds
• B. Adventitious breath sounds
• C. Absent breath sounds
• D. Diminished breath sounds

Correct answer: A

Rationale: During auscultation of the chest, normal breath sounds are the expected findings in a client who is newly admitted without respiratory complaints. Normal breath sounds indicate proper airflow through the airways without any abnormalities. Adventitious breath sounds (Choice B) refer to abnormal lung sounds such as crackles or wheezes, which are indicative of underlying respiratory issues. Absent breath sounds (Choice C) suggest a lack of airflow to a particular lung area, which could be due to conditions like pneumothorax. Diminished breath sounds (Choice D) indicate reduced airflow or consolidation in a specific lung region, often seen in conditions like pleural effusion or pneumonia. Therefore, in a newly admitted client without respiratory complaints, the nurse should expect to hear normal breath sounds during auscultation.

5. A client is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

• A. “This test will indicate if you are at risk for developing blood clots.”
• B. “This test will determine if your heart is performing properly.”
• C. “This test will provide information about the function of your liver.”
• D. “This test is used to check how your kidneys are working.”

Correct answer: C

Rationale: The correct answer is C: “This test will provide information about the function of your liver.” Alanine aminotransferase (ALT) is an enzyme mainly found in the liver. An elevated ALT level may indicate liver damage or disease. Choices A, B, and D are incorrect because ALT is specifically related to liver function and not indicative of blood clot risk, heart performance, or kidney function.

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