Nursing Elites

1. When admitting a client, what information should the nurse record in the client’s record first?

• A. Assessment of the client
• B. Client’s medical history
• C. Plan of care
• D. Vital signs

Correct answer: A

Rationale: When admitting a client, the nurse's first step should be to assess the client. Assessment is crucial as it helps establish a baseline of the client's condition, identify any immediate concerns, and guide the development of an individualized plan of care. Recording the client's medical history, plan of care, or vital signs may follow the initial assessment but are secondary to the primary assessment process.

2. The healthcare provider is caring for a client with a history of hypertension. Which assessment finding would be most concerning?

• A. Blood pressure of 150/90 mmHg
• B. Irregular heart rate
• C. Shortness of breath
• D. Headache

Correct answer: C

Rationale: Shortness of breath in a client with a history of hypertension is a critical assessment finding as it may indicate heart failure, pulmonary edema, or other severe complications. The development of shortness of breath suggests that the client's condition may be rapidly deteriorating and requires immediate medical attention. Elevated blood pressure (150/90 mmHg) is concerning but not as acute as the potential complications associated with shortness of breath. An irregular heart rate and headache can also be symptoms of hypertension, but in this scenario, shortness of breath poses a higher risk of severe cardiovascular or respiratory issues.

3. While documenting in a client’s medical record, which of the following entries should the nurse record?

• A. “Incision without redness or drainage”
• B. “Drank adequate amounts of fluid with meals”
• C. “Administered pain medication”
• D. “Oral temperature slightly elevated at 0800”

Correct answer: D

Rationale: The correct answer is D because documenting specific observations, such as an oral temperature being slightly elevated at a specific time, is crucial for monitoring the client's health status accurately. This type of information helps in assessing trends and changes in the client's condition over time. Choice A is incorrect as it lacks specificity and does not provide measurable data about the client's condition. Choice B is incorrect because it is a general statement related to client behavior rather than a specific health observation. Choice C is incorrect as it reflects an action taken by the nurse and not a direct client's condition or observation.

4. A young mother of three children complains of increased anxiety during her annual physical exam. What information should the LPN/LVN obtain first?

• A. Sexual activity patterns.
• B. Nutritional history.
• C. Leisure activities.
• D. Financial stressors.

Correct answer: B

Rationale: The LPN/LVN should first obtain the nutritional history in this scenario. Nutrition plays a crucial role in mental health, and deficiencies or imbalances in diet can contribute to anxiety symptoms. Understanding the mother's nutritional intake can help identify any factors exacerbating her anxiety. Sexual activity patterns are not directly relevant to her anxiety symptoms unless specifically indicated. Leisure activities and financial stressors may be important but are secondary to addressing the potential impact of nutrition on anxiety.

5. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?

• A. ''Incident report completed.''
• B. ''Client climbed over the bedrails.''
• C. ''Client found lying on the floor.''
• D. ''Client was trying to get out of bed.''

Correct answer: C

Rationale: The correct answer is C: ''Client found lying on the floor.'' In this situation, the nurse should document factual, objective information without making assumptions. Stating that the client was found lying on the floor directly reflects what was observed. Choice A, ''Incident report completed,'' is not a statement about the incident itself and does not provide relevant information. Choice B, ''Client climbed over the bedrails,'' introduces unnecessary speculation and assumption which should be avoided when documenting incidents. Choice D, ''Client was trying to get out of bed,'' focuses on the client's behavior rather than the objective observation of the client's position when found.

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