Nursing Elites

1. The nurse is planning care for a 12-year-old child with sickle cell disease in a vaso-occlusive crisis affecting the elbow. Which one of the following should be the priority?

• A. Limiting fluids
• B. Client-controlled analgesia
• C. Applying cold compresses to the elbow
• D. Performing passive range of motion exercises

Correct answer: B

Rationale: During a vaso-occlusive crisis in sickle cell disease, the priority intervention is effective pain management. Client-controlled analgesia allows the child to self-administer pain relief as needed, promoting comfort and reducing stress. Limiting fluids (choice A) is not appropriate in this scenario as hydration is essential to prevent complications. Cold compresses (choice C) may provide some comfort but do not address the underlying pain. Passive range of motion exercises (choice D) are contraindicated during a vaso-occlusive crisis due to the risk of further pain and tissue damage.

2. A client with chronic renal failure selects scrambled eggs for breakfast. What action should the LPN/LVN take?

• A. Commend the client for selecting a high biological value protein.
• B. Remind the client that protein in the diet should be avoided.
• C. Suggest that the client also select orange juice to promote absorption.
• D. Encourage the client to attend classes on dietary management of chronic renal failure.

Correct answer: A

Rationale: The correct action is to commend the client for selecting a high biological value protein, as scrambled eggs provide a good protein source for clients with chronic renal failure. Protein is essential for maintaining muscle mass and overall health in these clients. Reminding the client to avoid protein is incorrect as it may lead to protein-energy malnutrition, which is a common concern in chronic renal failure. Suggesting orange juice for absorption is not relevant to the situation, as protein absorption is not a primary concern in this context. Encouraging the client to attend classes on dietary management of chronic renal failure is important for overall education but is not the immediate action needed in response to the client's breakfast choice.

3. A client is having difficulty breathing while laying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?

• A. Suction the client's airway
• B. Administer a bronchodilator
• C. Increase the humidity in the client's room
• D. Assist the client to an upright position

Correct answer: D

Rationale: The correct answer is to assist the client to an upright position. When a client is having difficulty breathing, promoting optimal oxygenation is essential. Elevating the head of the bed improves ventilation and lung expansion by reducing pressure on the diaphragm. This position allows the lungs to expand fully, enhancing oxygen exchange. Suctioning the airway may be necessary if there are secretions causing obstruction, but it is not the first intervention in this scenario. Administering a bronchodilator is appropriate for bronchoconstriction but does not address the immediate need for better ventilation. Increasing humidity can be beneficial in certain respiratory conditions, but it is not the initial priority when a client is struggling to breathe.

4. A healthcare professional is caring for a client with a chest tube. Which observation requires immediate intervention?

• A. Constant bubbling in the suction control chamber
• B. Intermittent bubbling in the water seal chamber
• C. Drainage of 50 ml per hour
• D. Crepitus around the insertion site

Correct answer: D

Rationale: Crepitus around the chest tube insertion site may indicate subcutaneous emphysema, a serious condition that requires immediate attention. It can be a sign of an air leak in the lung or surrounding tissues. Constant bubbling in the suction control chamber is expected in a functioning chest tube system as it indicates proper suction. Intermittent bubbling in the water seal chamber is also normal, showing that the system is functioning correctly, allowing air to escape but not re-enter. Drainage of 50 ml per hour is within the expected range for chest tube output and does not require immediate intervention unless there are other concerning signs such as rapid increase or a sudden change in color or consistency.

5. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?

• A. I will avoid foods high in vitamin K.
• B. I will take my medication at the same time every day.
• C. I will use a soft toothbrush to prevent gum bleeding.
• D. I can take aspirin if I have a headache.

Correct answer: D

Rationale: The correct answer is 'D: I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or any other medications that can increase the risk of bleeding without consulting their healthcare provider. Choices A, B, and C are correct statements that demonstrate understanding of warfarin therapy and its potential side effects. Avoiding foods high in vitamin K helps maintain the effectiveness of warfarin, taking medication at the same time every day ensures consistent therapeutic levels, and using a soft toothbrush helps prevent gum bleeding, which can be a side effect of warfarin therapy.

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