Nursing Elites

1. The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver's license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next?

• A. Stand to the side of the patient's eye and observe the cornea.
• B. Conclude that the glasses were lost during the accident.
• C. Notify the ambulance personnel about the missing glasses.
• D. Ask the patient where the glasses are.

Correct answer: A

Rationale: In this scenario, the nurse should stand to the side of the patient's eye and observe the cornea. This action is crucial in assessing whether the patient wears contact lenses, especially in unresponsive patients. Observing the cornea can provide valuable information about the patient's eye health and potential use of contact lenses. Choices B, C, and D are incorrect. Concluding that the glasses were lost during the accident is premature without proper assessment. Notifying ambulance personnel about the missing glasses may not be the immediate priority, and asking the unresponsive patient about the glasses would not yield useful information in this situation.

2. A client who requires maximal support is being taught how to use a two-wheeled walker by a nurse. Which of the following actions by the client indicates an understanding of the teaching?

• A. The client moves the walker ahead 25.4 cm with each step
• B. The client picks up the walker with each step
• C. The client stands with elbows slightly bent while holding the walker
• D. The client stoops slightly forward when moving the walker

Correct answer: C

Rationale: The correct answer is C. When using a two-wheeled walker, the client should stand with elbows slightly bent to maintain balance and stability. This position helps distribute weight effectively and promotes proper use of the walker. Choices A, B, and D are incorrect. Choice A does not demonstrate proper posture while using the walker. Choice B of picking up the walker with each step is not the correct technique and can lead to instability. Choice D of stooping slightly forward is also incorrect as it can affect balance and posture negatively.

3. A client is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

• A. Hemolytic
• B. Allergic
• C. Febrile
• D. Transfusion-related acute lung injury (TRALI)

Correct answer: A

Rationale: The correct answer is A: Hemolytic. Hemolytic reactions can lead to flank pain and hemoglobinuria, as the body breaks down the transfused red blood cells. In hemolytic reactions, the immune system attacks and destroys the transfused red blood cells, causing the release of hemoglobin into the bloodstream and urine. This results in reddish-brown urine, indicating hemoglobinuria. Allergic reactions typically present with symptoms like itching, hives, or rash. Febrile reactions are characterized by fever, chills, and rigors. TRALI is a rare but serious transfusion reaction that manifests as acute respiratory distress following a transfusion, not flank pain and hemoglobinuria.

4. A client with a history of hypertension is prescribed a low-sodium diet. Which food should the LPN/LVN recommend the client avoid?

• A. Fresh fruits
• B. Grilled chicken
• C. Whole grain bread
• D. Canned soup

Correct answer: D

Rationale: The correct answer is D, canned soup. Canned soups are often high in sodium content, which can be harmful to individuals with hypertension following a low-sodium diet. Fresh fruits, grilled chicken, and whole grain bread are generally healthier options with lower sodium content and can be included in a low-sodium diet. Fresh fruits provide essential vitamins and minerals, grilled chicken is a lean protein source, and whole grain bread offers fiber and nutrients without excessive sodium levels. Avoiding canned soup aligns with the goal of reducing sodium intake to manage hypertension.

5. The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the nurse implement first?

• A. Check the drainage tubing for a kink
• B. Review the intake and output record
• C. Notify the healthcare provider
• D. Give the client 8 oz of water to drink

Correct answer: A

Rationale: The correct answer is to check the drainage tubing for a kink. A kink in the tubing can obstruct urine flow, potentially causing the low output. By addressing this first, the nurse can ensure that there are no physical obstructions hindering urine drainage. Reviewing the intake and output record is important, but addressing a possible kink in the tubing takes precedence as it directly affects urine flow. Notifying the healthcare provider should be considered after assessing and resolving immediate issues. Giving the client water to drink may be appropriate, but addressing a kink in the tubing is the priority to ensure proper function of the urinary catheter.

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