Nursing Elites

1. The LPN/LVN is assisting with the care of a client who has just had a liver biopsy. What position should the nurse place the client in immediately following the procedure?

• A. Supine with the right arm raised above the head
• B. Supine with the head of the bed elevated
• C. Right side-lying with a pillow under the costal margin
• D. Left side-lying with the head of the bed flat

Correct answer: C

Rationale: The correct position for a client immediately following a liver biopsy is right side-lying with a pillow under the costal margin. This position helps prevent bleeding by applying pressure to the biopsy site. Placing the client supine with the right arm raised above the head (Choice A) or supine with the head of the bed elevated (Choice B) are not ideal positions for post-liver biopsy care as they do not provide the necessary pressure to the biopsy site. Left side-lying with the head of the bed flat (Choice D) is also not recommended as it does not assist in preventing bleeding after a liver biopsy.

2. A client with a history of heart failure is admitted with weight gain and peripheral edema. Which medication should the LPN/LVN anticipate being prescribed?

• A. Lisinopril (Zestril)
• B. Furosemide (Lasix)
• C. Metoprolol (Lopressor)
• D. Simvastatin (Zocor)

Correct answer: B

Rationale: Furosemide (Lasix) is the correct answer. In a client with heart failure experiencing weight gain and peripheral edema, the priority is to manage fluid overload. Furosemide is a loop diuretic commonly prescribed to reduce excess fluid in heart failure patients. Lisinopril (Zestril) is an ACE inhibitor used to treat hypertension and heart failure but does not directly address fluid overload. Metoprolol (Lopressor) is a beta-blocker that helps manage heart failure symptoms but does not primarily target fluid retention. Simvastatin (Zocor) is a statin used to lower cholesterol levels and is not indicated for managing fluid overload in heart failure.

3. The nurse is teaching a client with newly diagnosed type 1 diabetes about insulin administration. Which statement by the client indicates a need for further teaching?

• A. I will rotate my injection sites to avoid lipodystrophy.
• B. I will check my blood sugar before meals and at bedtime.
• C. I will use the same needle for 3 days if I keep it clean.
• D. I will keep my insulin refrigerated until I need it.

Correct answer: C

Rationale: The correct answer is C because insulin needles should be disposed of after a single use to prevent infection. Reusing the same needle for three days can lead to infection and is not a safe practice. Choices A, B, and D demonstrate good understanding of insulin administration and diabetes management, so they do not indicate a need for further teaching.

4. A healthcare provider is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the healthcare provider take?

• A. Insert the IV catheter without using a tourniquet.
• B. Use the tourniquet minimally or not at all to avoid injury to fragile skin or veins.
• C. Insert the IV catheter at a 45-degree angle.
• D. Use a smaller gauge catheter to reduce vein trauma.

Correct answer: B

Rationale: When initiating IV therapy in older adults, it is essential to use the tourniquet minimally or not at all to prevent potential injury to fragile skin or veins. The use of a tourniquet can lead to increased venous pressure and potentially cause vein damage in older adult clients. Choice A is incorrect because inserting the IV catheter without a tourniquet can make locating veins more challenging. Choice C is incorrect as inserting the IV catheter at a 45-degree angle is not a recommended practice and can increase the risk of complications. Choice D is incorrect because using a smaller gauge catheter may not be appropriate for older adults who may require a larger gauge catheter for adequate fluid administration.

5. A client who is postoperative following abdominal surgery has an eviscerated wound. What should the nurse do first?

• A. Cover the incision with a moist sterile dressing.
• B. Notify the surgeon immediately.
• C. Assess the client's vital signs.
• D. Place the client in a supine position with knees bent.

Correct answer: A

Rationale: The initial action the nurse should take after discovering a client's eviscerated wound is to cover the incision with a moist sterile dressing. This step is crucial to protect the exposed tissue, prevent infection, and create a conducive environment for healing. While notifying the surgeon is important, addressing the wound immediately takes precedence. Assessing vital signs is essential but should follow the immediate intervention of covering the wound. Placing the client in a supine position with knees bent is not the priority in managing an eviscerated wound; the first step is to cover the wound to protect the exposed tissue.

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