Nursing Elites

1. The nurse is caring for a client who is post-operative following a cholecystectomy. Which assessment finding would require immediate intervention?

• A. Absent bowel sounds
• B. Pain level of 8/10
• C. Temperature of 100.4°F
• D. Saturated abdominal dressing

Correct answer: D

Rationale: A saturated abdominal dressing may indicate active bleeding or other complications that require immediate intervention, such as ensuring hemostasis and preventing further complications. Absent bowel sounds are common in the immediate post-operative period and may not require immediate intervention unless accompanied by other symptoms. A pain level of 8/10 can be managed with appropriate pain medication and is not typically considered an immediate priority unless other indications suggest complications. A temperature of 100.4°F is slightly elevated but may not be a cause for immediate concern unless it is associated with other signs of infection or distress that would warrant urgent attention.

2. A client with diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the LPN/LVN to take?

• A. Encourage the client to increase fluid intake.
• B. Monitor the client's blood glucose level.
• C. Administer insulin as prescribed.
• D. Assess the client's urine output.

Correct answer: B

Rationale: The correct answer is to monitor the client's blood glucose level. When a client with diabetes mellitus presents with symptoms of polyuria, polydipsia, and polyphagia, it indicates hyperglycemia. Monitoring blood glucose levels is crucial to assess and manage the client's condition effectively. Option A, encouraging the client to increase fluid intake, may exacerbate polyuria. Option C, administering insulin, should be done based on the healthcare provider's prescription after assessing the blood glucose level. Option D, assessing the client's urine output, is important but not the most immediate action needed in this scenario; monitoring blood glucose levels takes precedence.

3. When a client files a lawsuit against an LPN for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as:

• A. Evidence
• B. Tort discovery
• C. Proximate cause
• D. Common cause

Correct answer: C

Rationale: The correct answer is C, 'Proximate cause.' Proximate cause establishes the link between the harm suffered and the negligent actions performed by the nurse. In a malpractice lawsuit, proving proximate cause is essential to demonstrate that the nurse's actions directly led to the harm experienced by the client. Choice A, 'Evidence,' is incorrect as evidence is the information presented to support or refute a claim, not specifically the link between harm and negligence. Choice B, 'Tort discovery,' is incorrect as it does not specifically refer to establishing the link between harm and negligence. Choice D, 'Common cause,' is incorrect as it does not capture the legal concept of proximate cause in establishing liability in malpractice cases.

4. A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority?

• A. “I kind of like this boy in my class, but he doesn’t like me back.”
• B. “I want to hang out with the kids in the science club, but the jocks pick on them.”
• C. “I am so fat, I skip meals to try to lose weight.”
• D. “My dad wants me to be a lawyer like him, but I just want to dance.”

Correct answer: C

Rationale: The correct answer is C. Skipping meals to lose weight may indicate an eating disorder or significant distress, which can have serious health implications. This behavior raises concerns about the adolescent's physical and mental well-being. The nurse should prioritize addressing potential eating disorders and body image issues in this situation. Choices A, B, and D, while important, do not pose an immediate risk to the adolescent's health or well-being compared to the potential consequences of disordered eating behavior.

5. How can the LPN/LVN best handle the situation of a postoperative client being kept awake by a neighboring client with dementia who sings all night?

• A. Tell the neighboring client to stop singing.
• B. Close the doors to both clients' rooms at night.
• C. Give the complaining client the prescribed sedative as needed.
• D. Move the neighboring client to a room at the end of the hall.

Correct answer: D

Rationale: The best way to handle the situation in this scenario is to move the neighboring client to a room at the end of the hall. This solution is considerate to both clients because it addresses the issue by providing a quieter environment for the client with dementia while allowing the postoperative client to rest. Choice A is inappropriate as it does not address the root cause of the problem and may not be feasible or respectful. Choice B of closing the doors may not effectively reduce the noise disturbance. Choice C of giving the complaining client sedatives should be the last resort and not the initial solution, as it does not address the underlying issue causing the disturbance.

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