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. A client with a history of asthma is experiencing shortness of breath. What is the most appropriate action for the LPN/LVN to take first?

• A. Administer a bronchodilator as prescribed.
• B. Encourage the client to practice deep breathing exercises.
• C. Position the client in high Fowler's position.
• D. Obtain a peak flow reading.

Correct answer: A

Rationale: Administering a bronchodilator as prescribed is the most appropriate initial action for managing asthma-related shortness of breath. Bronchodilators help to open up the airways quickly, providing relief for the client. Encouraging deep breathing exercises may be beneficial in some situations but should not be the first action for acute shortness of breath in asthma. Positioning the client in high Fowler's position can also help improve breathing, but administering the bronchodilator takes precedence. Obtaining a peak flow reading is important in asthma management, but it is not the initial action needed to address acute shortness of breath.

3. The healthcare provider attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

• A. BP 142/88 mmHg
• B. 2+ edema of fingers and hands
• C. Radial pulse volume is +3
• D. Capillary refill time is 2 seconds

Correct answer: B

Rationale: Edema, indicated by 2+ edema of fingers and hands, can impair blood flow and peripheral perfusion, leading to reduced oxygen saturation readings on a pulse oximeter. High blood pressure (choice A) would not directly affect oxygen saturation readings. Radial pulse volume (choice C) and capillary refill time (choice D) are more related to assessing circulation rather than contributing significantly to oxygen saturation readings.

4. A healthcare professional is reviewing a client's fluid and electrolyte status. Which of the following findings should the healthcare professional report to the provider?

• A. BUN 15 mg/dL
• B. Creatinine 0.8 mg/dL
• C. Sodium 143 mEq/L
• D. Potassium 5.4 mEq/L

Correct answer: D

Rationale: The correct answer is D. A potassium level of 5.4 mEq/L is above the expected reference range, indicating hyperkalemia. Hyperkalemia can lead to serious complications such as dysrhythmias, making it important for the healthcare professional to report this finding to the provider for further evaluation and intervention. Choices A, B, and C fall within normal ranges and do not pose an immediate risk to the client's health, so they would not warrant immediate reporting to the provider. Elevated BUN or creatinine levels may indicate kidney dysfunction, while a sodium level of 143 mEq/L falls within the normal range for adults and does not typically require urgent intervention.

5. Which serum blood finding in diabetic ketoacidosis alerts the nurse that immediate action is required?

• A. pH below 7.3
• B. Potassium of 5.0
• C. HCT of 60
• D. PaO2 of 79%

Correct answer: C

Rationale: A hematocrit (HCT) of 60 indicates severe dehydration, a critical condition in diabetic ketoacidosis that requires immediate intervention. Severe dehydration can lead to hypovolemic shock and organ failure. While a low pH below 7.3 is indicative of acidosis, it may not require immediate action compared to severe dehydration. A potassium level of 5.0 is within the normal range and not a critical finding in this scenario. PaO2 of 79% reflects oxygenation status, which is important but not the most critical finding requiring immediate action in diabetic ketoacidosis.

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