Nursing Elites

1. While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds?

• A. Hypoactive bowel sounds
• B. Low-pitched bowel sounds
• C. Hyperactive bowel sounds
• D. An absence of bowel sounds

Correct answer: C

Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hyperactive bowel sounds are loud, high-pitched, and rushing sounds. Hypoactive bowel sounds are low-pitched and may occur post-surgery or with peritoneal inflammation. Low-pitched bowel sounds are not typically associated with borborygmus. An absence of bowel sounds indicates a potentially serious issue like an ileus, where bowel motility is decreased or absent.

2. A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats/min. On the basis of this finding, which priority action should the nurse take?

• A. Continuing to check the client's vital signs every 15 minutes
• B. Notifying the registered nurse immediately
• C. Checking the client's uterine fundus
• D. Documenting the vital signs in the client's medical record

Correct answer: C

Rationale: During the fourth stage of labor, the woman's vital signs should be assessed every 15 minutes during the first hour. An increasing pulse rate is an early sign of excessive blood loss, as the heart beats faster to compensate for reduced blood volume. The blood pressure decreases as blood volume diminishes, but this is a later sign of hypovolemia. The most common reason for excessive postpartum bleeding is a uterus that is not firmly contracting and compressing open vessels at the placental site. Therefore, the nurse should check the client's uterine fundus for firmness, height, and positioning. Checking the uterine fundus is the priority action as it helps determine if the client is bleeding excessively. Notifying the registered nurse immediately is not necessary unless the cause of bleeding is unclear and needs further intervention. Continuing to check vital signs without addressing the potential issue will delay necessary intervention. Documenting findings is important, but not the immediate priority when faced with a potential emergency situation like postpartum hemorrhage.

3. The LPN is taking care of a 176-pound client who has recently been diagnosed with diabetes. The primary healthcare provider has written an order for Lantus� (insulin glargine injection) 100 units/mL, using weight-based dosing of 0.2 units/kg per day. The LPN should prepare ____ units for administration.

• A. 12
• B. 35
• C. 16
• D. 9

Correct answer: B

Rationale: To calculate the correct dosage, first convert the client's weight from pounds to kilograms. As 1 kg = 2.2 pounds, 176 pounds � 2.2 = 80 kg. The client should receive 0.2 units for every kilogram, which equals 16 units. Therefore, the total amount to prepare is 16 units x 100 units/mL = 1600 units. Considering the medication concentration of 100 units/mL, 1600 units � 100 units/mL = 16 mL. However, since the question asks for the number of units, the final answer is 16 units x 2 injections = 32 units. Therefore, the LPN should prepare 32 units for administration.

4. The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?

• A. The client should remove all scatter rugs from the floor and minimize clutter.
• B. The client should not limit her movement within the home unless advised by the physician.
• C. The client should have a raised toilet seat and grab bars available in the bathroom.
• D. The client should not wear a robe and socks while walking in the house.

Correct answer: A

Rationale: The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.

5. A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. The nurse should provide which information?

• A. Clients must stay at home and ask a neighbor or family member to run their errands.
• B. It is best to do grocery shopping and other errands early in the morning when crowds are smaller.
• C. Clients should wash their hands frequently and keep hands away from the face, especially during peak flu season.
• D. Drinking eight 8-oz glasses of fluid each day will reduce the risk of contracting influenza.

Correct answer: C

Rationale: During peak influenza season, older clients should take measures to reduce the risk of contracting the flu. The most effective preventive measure is frequent hand hygiene and refraining from touching the face, as this reduces the transmission of the flu virus. While it is advisable to avoid crowds, the direct action of hand hygiene is more impactful. Doing errands early in the morning when crowds are smaller is a good suggestion to reduce exposure but does not address the direct transmission through hands. Drinking enough fluid daily is important for overall health but does not directly reduce the risk of contracting influenza.

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