Nursing Elites

1. Postoperatively, signs of hemorrhagic shock are observed. The nurse notifies the surgeon, who instructs to continue monitoring vitals every 15 minutes and report back in one hour. What should the nurse do next?

• A. Notify the nurse manager
• B. Continue monitoring as instructed
• C. Administer IV fluids as per protocol
• D. Prepare for immediate transfer to the ICU

Correct answer: B

Rationale: The correct answer is to continue monitoring the patient as instructed. This is crucial to assess the patient's condition and response to initial interventions. Administering IV fluids or preparing for transfer to the ICU should only be done based on further assessment or explicit orders from the healthcare provider. Notifying the nurse manager, as suggested in choice A, without further assessment or intervention could delay immediate patient care and management.

2. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?

• A. Remove clocks from the client’s room
• B. Use full-length side rails on the client’s bed
• C. Check on the client frequently while they are in the restroom
• D. Encourage physical activity throughout the day to expend energy

Correct answer: D

Rationale: Encouraging physical activity throughout the day is an effective way to manage confusion in clients and reduce the need for restraints. Physical activity helps in expending energy, promoting circulation, and improving overall well-being. Removing clocks from the client’s room (choice A) may not directly address the issue of confusion or reduce the need for restraints. Using full-length side rails on the client’s bed (choice B) can actually increase the risk of entrapment and should be avoided. Checking on the client frequently while they are in the restroom (choice C) is important for monitoring safety but may not directly address the underlying issue of confusion and the need for restraints.

3. A client with a tracheostomy is being taught by a nurse and their family how to care for the tracheostomy at home. Which of the following should the nurse include in the teaching?

• A. Use tracheostomy covers when outdoors.
• B. Clean the tracheostomy with alcohol.
• C. Replace the tracheostomy tube every week.
• D. Cover the tracheostomy with a wet cloth when sleeping.

Correct answer: A

Rationale: Using tracheostomy covers when outdoors is essential to protect the tracheostomy from dust and debris, reducing the risk of infection. Tracheostomy covers help maintain cleanliness and prevent foreign particles from entering the stoma. Choice B is incorrect because cleaning the tracheostomy with alcohol can be too harsh and drying for the skin surrounding the stoma, leading to skin irritation. Choice C is incorrect as tracheostomy tubes are typically replaced only when clinically indicated or as per the healthcare provider's instructions, not routinely every week, to prevent unnecessary risks and complications. Choice D is incorrect as covering the tracheostomy with a wet cloth when sleeping can create a moist environment ideal for bacterial growth, increasing the risk of infection and skin breakdown. It is important to keep the tracheostomy site clean, dry, and protected to maintain optimal hygiene and prevent complications.

4. When providing mouth care for an unconscious client, what action should the nurse take?

• A. Turn the client’s head to the side.
• B. Place two fingers in the client’s mouth to open it.
• C. Brush the client’s teeth once per day.
• D. Inject mouth rinse into the center of the client’s mouth.

Correct answer: A

Rationale: When providing mouth care for an unconscious client, the nurse should turn the client’s head to the side. This action helps prevent aspiration by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Placing fingers into the client’s mouth can be dangerous and may cause injury. Brushing the client’s teeth only once a day may not be sufficient for proper oral hygiene care. Injecting mouth rinse into the center of the mouth is not recommended and can potentially lead to aspiration. Therefore, the correct action for the nurse to take is to turn the client’s head to the side.

5. 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.

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