Nursing Elites

1. UAP has lowered the head of the bed to change the linens for a client who is bedridden. Which observation...most immediate intervention by the nurse?

• A. A feeding is infusing at 40 mL/hr through an enteral feeding tube.
• B. The urine meter attached to the urinary drainage bag is completely full.
• C. There is a large dependent loop in the client's urinary drainage tubing.
• D. Purulent drainage is present around the insertion site of the feeding tube.

Correct answer: D

Rationale: The correct answer is D. Purulent drainage around the insertion site of the feeding tube indicates an infection, which requires immediate attention. This may be a sign of a serious complication that needs prompt nursing intervention to prevent further complications or deterioration in the client's condition. Choices A, B, and C do not indicate an immediate threat to the client's health. While option A highlights the infusion rate of the feeding, it does not pose an immediate risk compared to the presence of purulent drainage indicating infection.

2. A nurse is caring for a client postoperatively. When the nurse prepares to change the dressing, the client says it hurts. Which intervention is the nurse’s priority action?

• A. Administer pain medication 45 minutes prior to dressing change.
• B. Change the dressing quickly to minimize pain.
• C. Provide reassurance to the client that the pain will pass.
• D. Use a less painful dressing technique.

Correct answer: A

Rationale: Administering pain medication before the dressing change is the priority action to help manage the client's pain effectively. This intervention ensures that the client is comfortable during the procedure. Changing the dressing quickly may cause more discomfort to the client. Providing reassurance is important but does not address the immediate pain concern. Using a less painful dressing technique may be helpful, but administering pain medication first is the priority to address the client's pain promptly.

3. What is the most important assessment for the LPN/LVN to perform on a client with a history of chronic obstructive pulmonary disease (COPD) receiving oxygen therapy at 2 liters per minute via nasal cannula?

• A. Assess the client's respiratory rate and effort.
• B. Measure the client's oxygen saturation level.
• C. Monitor the client's arterial blood gas levels.
• D. Check the client's blood pressure.

Correct answer: B

Rationale: Measuring the client's oxygen saturation level is the most important assessment in this scenario. Oxygen saturation level reflects how well the client is oxygenating, which is crucial in assessing the effectiveness of oxygen therapy for a client with COPD. Monitoring the respiratory rate and effort (Choice A) is important but assessing oxygenation with saturation levels takes precedence. While arterial blood gas levels (Choice C) provide comprehensive information, checking oxygen saturation is a quicker and more immediate way to assess oxygenation status. Checking blood pressure (Choice D) is not the priority when evaluating the effectiveness of oxygen therapy in COPD.

4. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that are associated with this problem include which of these?

• A. Lymphedema and nerve palsy
• B. Hearing loss and ataxia
• C. Headaches and vomiting
• D. Abdominal mass and weakness

Correct answer: D

Rationale: The correct answer is D: Abdominal mass and weakness. In neuroblastoma, the most common presenting signs are related to the mass effect of the tumor, leading to an abdominal mass and symptoms of weakness. Lymphedema and nerve palsy (Choice A) are not typically associated with neuroblastoma. Hearing loss and ataxia (Choice B) are more indicative of other conditions like neurofibromatosis or brain tumors. Headaches and vomiting (Choice C) are more commonly seen in conditions such as brain tumors or increased intracranial pressure, but they are not specific to neuroblastoma.

5. The healthcare provider is caring for a client with dehydration. Which assessment finding indicates that the client is responding to treatment?

• A. Dry mucous membranes
• B. Increased urine output
• C. Decreased heart rate
• D. Elevated blood pressure

Correct answer: B

Rationale: Increased urine output is the correct assessment finding that indicates the client is responding to treatment for dehydration. When a client is dehydrated, their urine output tends to decrease as the body tries to conserve fluids. Therefore, an increase in urine output suggests that the client's hydration status is improving. Dry mucous membranes (Choice A) are a sign of dehydration and would not indicate a positive response to treatment. Decreased heart rate (Choice C) and elevated blood pressure (Choice D) are not specific indicators of hydration status in a client with dehydration.

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