Nursing Elites

1. The nurse is caring for a client with diabetes insipidus. Which finding should the LPN/LVN report to the healthcare provider?

• A. Weight gain
• B. Increased urine output
• C. Low blood pressure
• D. Thirst

Correct answer: B

Rationale: The correct answer is B: Increased urine output. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large amounts of dilute urine. Reporting increased urine output is crucial as it is a hallmark sign of diabetes insipidus. Weight gain (choice A) is not typically associated with diabetes insipidus; instead, clients may experience weight loss due to fluid loss. Low blood pressure (choice C) can be a complication of diabetes insipidus due to dehydration from excessive urination, but the priority finding to report is the increased urine output. Thirst (choice D) is a common symptom of diabetes insipidus due to the body's attempt to compensate for fluid loss, but it is not the most critical finding to report.

2. The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?

• A. Swelling and redness in the affected leg
• B. Pain in the affected leg
• C. Warmth and tenderness in the affected leg
• D. A positive Homans' sign

Correct answer: D

Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.

3. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?

• A. Wear cotton clothing to avoid static electricity.
• B. Avoid using any electrical appliances.
• C. Keep the oxygen tank away from heat sources.
• D. Use only a specific type of nasal cannula.

Correct answer: A

Rationale: The correct answer is A: Wear cotton clothing to avoid static electricity. When using oxygen therapy, static electricity can pose a hazard as it increases the risk of fire. Cotton clothing helps reduce static electricity buildup. Choice B, avoiding electrical appliances, is overly restrictive and not entirely necessary. Choice C, keeping the oxygen tank away from heat sources, is important to prevent fire hazards but is not directly related to the nasal cannula. Choice D, using only a specific type of nasal cannula, is not a universal guideline and limits flexibility in care.

4. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

• A. Assign the client to a room with a negative air-flow system.
• B. Use alcohol-based hand sanitizer when leaving the client's room.
• C. Clean contaminated surfaces in the client's room with a phenol solution.
• D. Have family members wear a gown and gloves when visiting.

Correct answer: D

Rationale: When caring for clients with Clostridium difficile infection, it is important to prevent the transmission of spores. Having family members wear a gown and gloves when visiting helps reduce the spread of the infection. Choices A, B, and C are incorrect because assigning the client to a room with a negative air-flow system, using alcohol-based hand sanitizer, and cleaning surfaces with a phenol solution are not specific measures targeted at preventing the transmission of Clostridium difficile spores.

5. A client with heart failure is being taught by a nurse on reducing daily sodium intake. Which factor is most crucial in determining the client’s ability to learn new dietary habits?

• A. The client's involvement in planning the change
• B. The cost of the dietary changes
• C. The availability of low-sodium foods
• D. The client’s previous dietary knowledge

Correct answer: D

Rationale: The client’s previous dietary knowledge is the most critical factor in determining the ability to learn new dietary habits. Understanding the client's existing dietary knowledge helps tailor the teaching to build upon what they already know. While client involvement in planning changes can increase adherence and motivation, the foundational knowledge is essential for effective learning. The cost of dietary changes and the availability of low-sodium foods are important considerations but not as crucial as the client's existing knowledge.

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