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. An unlicensed assistive personnel (UAP) places a client in a left lateral position before administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP?

• A. Position the client on the right side of the bed in reverse Trendelenburg.
• B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
• C. Reposition the client in a Sim's position with the weight on the anterior ilium.
• D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Correct answer: C

Rationale: The correct instruction the LPN/LVN should provide to the UAP is to reposition the client in a Sim's position with the weight on the anterior ilium for administering a soap suds enema. This position helps facilitate the administration of the enema by providing better access and comfort for the client. Choice A is incorrect as reverse Trendelenburg is not the appropriate position for administering a soap suds enema. Choice B is incorrect as the concentration of soap in the enema solution is not specified and might be too strong. Choice D is incorrect as raising the side rails and elevating the bed does not directly relate to the proper positioning for administering the enema.

3. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

• A. Sit on the toilet 30 minutes after eating a meal.
• B. Increase your fluid intake to help with bowel movements.
• C. Exercise regularly to improve bowel function.
• D. Consume more high-fiber foods to prevent constipation.

Correct answer: A

Rationale: The correct statement the nurse should include in the teaching is to 'Sit on the toilet 30 minutes after eating a meal.' This advice can help establish a regular bowel routine and improve bowel movement. Option B, 'Increase your fluid intake to help with bowel movements,' while important, is not specific to the time after eating and does not directly address the need for establishing a routine. Option C, 'Exercise regularly to improve bowel function,' is also important but does not address the timing of bowel movements. Option D, 'Consume more high-fiber foods to prevent constipation,' is beneficial for preventing constipation but does not address the timing aspect related to bowel movements.

4. A healthcare professional is preparing to administer dextrose 5% in water (D5W) 1,000-mL IV to infuse over 10 hr. How many mL/hr should the IV infusion pump be set to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)

• A. 100 mL/hr
• B. 150 mL/hr
• C. 75 mL/hr
• D. 50 mL/hr

Correct answer: A

Rationale: To infuse 1,000 mL over 10 hr, the IV pump should be set to deliver 100 mL/hr. This calculation is derived by dividing the total volume (1,000 mL) by the total time in hours (10 hr), resulting in the infusion rate of 100 mL/hr. Choices B, C, and D are incorrect as they do not accurately reflect the correct calculation for this scenario.

5. An 18-year-old client is admitted to the intensive care unit from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebra. The nurse's priority assessment should be

• A. Response to stimuli
• B. Bladder control
• C. Respiratory function
• D. Muscle strength

Correct answer: C

Rationale: Injuries at the level of the 2nd cervical vertebra can affect the phrenic nerve, leading to potential impairment of respiratory function. Assessing respiratory function is crucial as compromised breathing can quickly escalate to life-threatening situations. While response to stimuli is important, ensuring adequate oxygenation takes precedence due to the immediate threat to life. Bladder control may be affected by spinal cord injuries at higher levels, but it is not the priority in this scenario. Muscle strength is a potential consequence of cervical spinal cord injury, but assessing respiratory function is more critical in the acute phase.

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