Nursing Elites

1. Which goal is most appropriate for a patient who has had a total hip replacement?

• A. The patient will ambulate briskly on the treadmill by the time of discharge.
• B. The patient will walk 100 feet using a walker by the time of discharge.
• C. The nurse will assist the patient to ambulate in the hall 2 times a day.
• D. The patient will ambulate by the time of discharge.

Correct answer: B

Rationale: The goal 'The patient will walk 100 feet using a walker by the time of discharge' is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, achievable, and individualized. This goal sets a clear target for the patient's mobility progress post-surgery. Choice A is too vague and does not provide a specific target distance or method of ambulation. Choice C focuses on the nurse's actions rather than the patient's progress. Choice D lacks specificity in terms of distance or assistance required, making it less measurable and individualized compared to Choice B.

2. When providing mouth care for an unconscious client, what action should the nurse take?

• A. Turn the client’s head to the side.
• B. Place two fingers in the client’s mouth to open it.
• C. Brush the client’s teeth once per day.
• D. Inject mouth rinse into the center of the client’s mouth.

Correct answer: A

Rationale: When providing mouth care for an unconscious client, the nurse should turn the client’s head to the side. This action helps prevent aspiration by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Placing fingers into the client’s mouth can be dangerous and may cause injury. Brushing the client’s teeth only once a day may not be sufficient for proper oral hygiene care. Injecting mouth rinse into the center of the mouth is not recommended and can potentially lead to aspiration. Therefore, the correct action for the nurse to take is to turn the client’s head to the side.

3. A healthcare professional is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the healthcare professional identify as an indication that the treatment was successful?

• A. Increase in hematocrit
• B. Increase in respiratory rate
• C. Decrease in heart rate
• D. Decrease in capillary refill time

Correct answer: C

Rationale: Fluid-volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range. An increase in hematocrit (Choice A) would indicate hemoconcentration, not a successful fluid replacement. An increase in respiratory rate (Choice B) could indicate respiratory distress or hypoxia, not improvement in fluid volume status. A decrease in capillary refill time (Choice D) may indicate improved peripheral perfusion but is not a direct indicator of fluid replacement success.

4. 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.

5. What advice should the client be given if they are feeling dizzy upon standing after taking a diuretic for hypertension?

• A. Avoid standing up too quickly.
• B. Increase fluid intake to stay hydrated.
• C. Eat more salt to help retain fluids.
• D. Wear compression stockings during the day.

Correct answer: A

Rationale: The correct advice for a client feeling dizzy upon standing after taking a diuretic for hypertension is to avoid standing up too quickly. Diuretics can lead to orthostatic hypotension, causing dizziness upon sudden position changes. Increasing fluid intake can exacerbate the issue by further lowering blood pressure. Eating more salt might counteract the diuretic's effects but is not the primary intervention for orthostatic hypotension. Compression stockings are more relevant for venous insufficiency than for orthostatic hypotension.

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