Nursing Elites

1. To minimize the side effects of vincristine (Oncovin) that a client is receiving, what does the LPN/LVN expect the dietary plan to include?

• A. Low in fat
• B. High in iron
• C. High in fluids
• D. Low in residue

Correct answer: C

Rationale: The correct answer is to include a diet high in fluids to help minimize the side effects of vincristine. High fluid intake is important in managing potential side effects such as constipation, which is a common issue associated with vincristine therapy. Options A, B, and D are incorrect. A diet low in fat or high in iron is not specifically indicated for managing vincristine side effects. Additionally, a diet low in residue is not directly related to addressing vincristine side effects.

2. What are the correct steps used for abdominal assessment?

• A. Inspection, auscultation, percussion, palpation
• B. Palpation, inspection, auscultation, percussion
• C. Percussion, palpation, inspection, auscultation
• D. Auscultation, palpation, percussion, inspection

Correct answer: A

Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection allows the nurse to visually assess the abdomen for any abnormalities or distension. Auscultation follows to listen for bowel sounds and vascular sounds. Percussion helps to assess the density of underlying structures and detect any abnormal masses. Palpation is performed last to assess tenderness, organ size, and detect any masses. Choices B, C, and D have the steps in the incorrect order, making them the wrong choices.

3. A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?

• A. A client who has new onset of dyspnea 24 hours after a total hip arthroplasty
• B. A client who has acute abdominal pain rated 4 on a scale from 0 to 10
• C. A client who has a UTI and low-grade fever
• D. A client who has pneumonia and an oxygen saturation of 96%

Correct answer: A

Rationale: The nurse should see the client who has new onset of dyspnea 24 hours after a total hip arthroplasty first. New onset of dyspnea, especially after surgery, can indicate a serious complication such as a pulmonary embolism or deep vein thrombosis. It is essential to assess this client promptly to rule out potentially life-threatening conditions. Acute abdominal pain, a UTI with low-grade fever, and pneumonia with an oxygen saturation of 96% are important issues but do not indicate the urgency and potential severity of a post-operative complication like pulmonary embolism or deep vein thrombosis.

4. A client has restraints on each extremity. Which of the following assessments should the nurse perform first?

• A. Peripheral pulses
• B. Comfort level
• C. Elimination needs
• D. Skin integrity

Correct answer: A

Rationale: When a client is restrained, the nurse should prioritize assessing peripheral pulses first. This assessment is crucial to monitor circulation and ensure the restraints are not impeding blood flow. Comfort level, elimination needs, and skin integrity are also important assessments; however, assessing peripheral pulses takes precedence to prevent complications such as impaired circulation and tissue damage. By assessing peripheral pulses initially, the nurse can promptly identify and address any circulation issues, which are critical in preventing serious complications.

5. A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?

• A. Chest pain
• B. Pallor
• C. Inspiratory crackles
• D. Heart murmur

Correct answer: C

Rationale: Inspiratory crackles are a common finding in patients with congestive heart failure due to the accumulation of fluid in the lungs, leading to crackling sounds during inspiration. Chest pain (Choice A) is more commonly associated with conditions like angina or myocardial infarction and is not a typical symptom of congestive heart failure. Pallor (Choice B) is a general symptom of various conditions and not specific to congestive heart failure. While a heart murmur (Choice D) may be heard in some cases of congestive heart failure, it is not as consistent as inspiratory crackles in indicating the condition.

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