Nursing Elites

1. The healthcare provider is assessing a client with suspected tuberculosis. Which symptom would be most concerning?

• A. Night sweats
• B. Weight loss
• C. Cough with bloody sputum
• D. Fatigue

Correct answer: C

Rationale: Cough with bloody sputum is a hallmark symptom of tuberculosis and is highly concerning as it indicates active disease. Hemoptysis (coughing up blood) is associated with tuberculosis infection in the lungs. While night sweats and weight loss are common symptoms of tuberculosis, they are less specific than coughing with bloody sputum. Fatigue is a nonspecific symptom that can be present in various conditions and is not specific to tuberculosis.

2. The nurse is caring for a client with a nasogastric (NG) tube. Which action should the LPN/LVN take to maintain patency of the tube?

• A. Flush the tube with 30 ml of water before and after medication administration.
• B. Secure the tube to the client's gown.
• C. Check the placement of the tube by auscultation.
• D. Irrigate the tube with normal saline every shift.

Correct answer: A

Rationale: The correct action to maintain patency of a nasogastric (NG) tube is to flush the tube with water before and after medication administration. Flushing helps prevent clogging and ensures that the tube remains clear for proper functioning. Securing the tube to the client's gown (Choice B) is important for stability but does not directly address tube patency. Checking the placement of the tube by auscultation (Choice C) is crucial for verifying correct placement but does not specifically relate to maintaining tube patency. Irrigating the tube with normal saline every shift (Choice D) is not a routine practice for maintaining tube patency and can lead to electrolyte imbalances.

3. When admitting a client, what information should the nurse record in the client’s record first?

• A. Assessment of the client
• B. Client’s medical history
• C. Plan of care
• D. Vital signs

Correct answer: A

Rationale: When admitting a client, the nurse's first step should be to assess the client. Assessment is crucial as it helps establish a baseline of the client's condition, identify any immediate concerns, and guide the development of an individualized plan of care. Recording the client's medical history, plan of care, or vital signs may follow the initial assessment but are secondary to the primary assessment process.

4. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which of the following laboratory values would be most concerning?

• A. INR of 1.5
• B. Platelet count of 200,000/mm³
• C. Hemoglobin of 12 g/dL
• D. aPTT of 70 seconds

Correct answer: A

Rationale: An INR of 1.5 is below the therapeutic range for clients on anticoagulation therapy, increasing the risk of clot formation. A lower INR indicates inadequate anticoagulation, which can lead to thrombus formation and potential complications such as progression or recurrence of deep vein thrombosis. Platelet count, hemoglobin level, and aPTT are important parameters to monitor in a client with DVT. However, in this scenario, the most concerning value is the suboptimal INR level because it signifies a lack of anticoagulation effectiveness and poses a higher risk of clotting issues.

5. A client who has recently started using a behind-the-ear hearing aid is being cared for by a nurse. Which of the following statements should the nurse identify as an indication that the client understands the use of assistive devices?

• A. “I will be sure to remove my hearing aid before taking a shower.”
• B. “I will keep my hearing aid in at all times, even when sleeping.”
• C. “I will clean my hearing aid with alcohol.”
• D. “I will turn off my hearing aid when not in use.”

Correct answer: A

Rationale: The correct answer is A. It is crucial for the client to remove the hearing aid before showering to prevent damage from moisture. Choice B is incorrect as wearing the hearing aid all the time, including during sleep, is not recommended and can cause discomfort or harm. Choice C is incorrect as alcohol can damage hearing aids; they should be cleaned with a solution recommended by the manufacturer to prevent harm. Choice D is incorrect because hearing aids should not be turned off when not in use; instead, they should be stored properly following the manufacturer's instructions to maintain functionality and battery life.

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