Nursing Elites

1. The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the LPN that this client understands the dietary restrictions?

• A. Tossed salad with low-sodium dressing, bacon, and tomato sandwich.
• B. New England clam chowder, unsalted crackers, fresh fruit salad.
• C. Skim milk, turkey salad, roll, and vanilla ice cream.
• D. Macaroni and cheese, diet Coke, and a slice of cherry pie.

Correct answer: C

Rationale: The correct answer is C: Skim milk, turkey salad, roll, and vanilla ice cream. These items are low in sodium, making it a suitable meal for someone on a low-sodium diet. Skim milk, turkey salad, and vanilla ice cream are naturally low in sodium, while the roll can be selected as a low-sodium option. Choices A, B, and D contain items that are typically high in sodium, such as bacon, clam chowder, crackers, and cheese, making them unsuitable for a low-sodium diet.

2. In an emergency department, a nurse is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hours. Which of the following actions should the nurse take first?

• A. Auscultate bowel sounds.
• B. Administer an antiemetic.
• C. Offer pain medication.
• D. Palpate the abdomen.

Correct answer: A

Rationale: The correct action the nurse should take first is to auscultate bowel sounds. This step is crucial to assess bowel activity before proceeding with palpation or administering medications. Assessing bowel sounds can provide valuable information about bowel motility and potential obstructions. Administering an antiemetic or offering pain medication may be necessary but should come after assessing bowel sounds to ensure appropriate treatment. Palpating the abdomen should be avoided initially to prevent potential discomfort or complications, especially if there is suspected abdominal pathology.

3. The healthcare provider is caring for a client receiving chemotherapy. Which finding should the LPN/LVN report to the healthcare provider immediately?

• A. Mild nausea
• B. Hair loss
• C. Increased fatigue
• D. Fever of 101.5°F (38.6°C)

Correct answer: D

Rationale: A fever of 101.5°F (38.6°C) in a client undergoing chemotherapy is a significant finding that may indicate an underlying infection, which can be life-threatening due to the client's compromised immune system. Prompt reporting and intervention are crucial to prevent complications. Mild nausea, hair loss, and increased fatigue are common side effects of chemotherapy and are expected findings that do not typically require immediate reporting unless they are severe or significantly impacting the client's well-being. Therefore, the LPN/LVN should prioritize reporting the fever over the other options.

4. A client reports having insomnia. Which of the following interventions is appropriate for the nurse to recommend?

• A. Exercise 1 hour before bedtime.
• B. Eat a light carbohydrate snack before bedtime.
• C. Drink a cup of hot cocoa before bedtime.
• D. Take a 30-minute nap daily.

Correct answer: B

Rationale: Eating a light carbohydrate snack before bedtime is a suitable intervention for insomnia because it can help stabilize blood sugar levels and promote sleep. Exercising close to bedtime may actually disrupt sleep patterns due to increased alertness and body temperature. Drinking hot cocoa before bedtime, which contains caffeine, may interfere with falling asleep. Taking a nap during the day can make it harder to fall asleep at night and may worsen insomnia. Therefore, the best recommendation among the choices provided is to eat a light carbohydrate snack before bedtime.

5. A client is 24 hours postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for “real food.” The nurse tells the client, “I will call the surgeon and ask for a change in diet.” The surgeon hears the nurse’s report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking?

• A. Basic
• B. Commitment
• C. Complex
• D. Integrity

Correct answer: C

Rationale: The nurse demonstrated complex critical thinking by assessing the client's condition, evaluating the need for a change, and making a recommendation to the surgeon. In this scenario, the nurse went beyond simply following instructions or making routine decisions (basic critical thinking). There was a depth of analysis and decision-making involved, showing a higher level of critical thinking than basic or commitment levels. Integrity is about adherence to ethical principles and honesty, not directly related to the critical thinking process.

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