Nursing Elites

1. While administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?

• A. Have the client hold their breath briefly and bear down.
• B. Clamp the enema tubing.
• C. Remind the client that cramping is common at this time.
• D. Raise the level of the enema fluid container.

Correct answer: C

Rationale: When a client reports abdominal cramping during a cleansing enema, it is important for the nurse to reassure the client that cramping is a common side effect. This reassurance helps the client understand that the cramping is normal and may subside once the enema is completed. Instructing the client to hold their breath and bear down (Choice A) is not appropriate and may cause discomfort. Clamping the enema tubing (Choice B) is unnecessary and could lead to complications. Raising the level of the enema fluid container (Choice D) does not address the client's discomfort due to cramping. Therefore, the most suitable action is to provide reassurance to the client about the common occurrence of cramping during the enema.

2. 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.

3. A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dL. What is the priority nursing action for the LPN/LVN?

• A. Administer insulin as prescribed.
• B. Administer oral hypoglycemic agents.
• C. Monitor blood glucose levels frequently.
• D. Provide a high-calorie diet.

Correct answer: A

Rationale: The correct answer is to administer insulin as prescribed. When a client with diabetes mellitus presents with a critically high blood glucose level like 600 mg/dL, the priority action is to lower the blood glucose level promptly to prevent complications. Insulin is the appropriate medication to rapidly reduce high blood glucose levels. Administering oral hypoglycemic agents may not act quickly enough in this critical situation. While monitoring blood glucose levels frequently is important, immediate intervention to lower the high blood glucose level takes precedence. Providing a high-calorie diet is contraindicated in this scenario as it would further elevate the blood glucose level.

4. The nurse is preparing to assist a newly admitted client with personal hygiene measures. The nurse wants to assess the client's gag reflex. Which action should the nurse include?

• A. Offer small sips of water through a straw
• B. Place tongue blade on back half of tongue
• C. Use a penlight to observe back of the oral cavity
• D. Auscultate breath sounds after the client swallows

Correct answer: B

Rationale: The correct action for the nurse to include when assessing the client's gag reflex is to place a tongue blade on the back half of the tongue. This method effectively tests the gag reflex without causing discomfort. Choice A is incorrect because offering small sips of water through a straw does not assess the gag reflex. Choice C is incorrect as using a penlight to observe the back of the oral cavity does not directly assess the gag reflex. Choice D is incorrect since auscultating breath sounds after the client swallows does not evaluate the gag reflex.

5. A patient uses an in-the-canal hearing aid. Which assessment is a priority?

• A. Eyeglass usage
• B. Cerumen buildup
• C. Type of physical exercise
• D. Excessive moisture problems

Correct answer: B

Rationale: When a patient uses an in-the-canal hearing aid, cerumen buildup is a critical issue that needs to be regularly assessed. Cerumen can easily block the sound passage and affect the functionality of the hearing aid. Assessing and managing cerumen buildup is a priority to ensure the proper functioning of the hearing aid. Eyeglass usage, type of physical exercise, and excessive moisture problems are not directly related to the specific issue of cerumen buildup in in-the-canal hearing aids, making them lower priority assessments in this context.

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