Nursing Elites

1. You are caring for a 78-year-old woman who is wondering why she was diagnosed with glaucoma. Although she has several risk factors, which of these is not one of them?

• A. age
• B. blood pressure reading of 143/89
• C. Mexican-American heritage
• D. 20/80 vision

Correct answer: D

Rationale: Age over 60 and Mexican-American heritage are recognized as risk factors for glaucoma. Elevated blood pressure is also a risk factor due to its potential to cause optic nerve damage. While 20/80 vision indicates poor eyesight, it is not a direct causal factor for glaucoma. Glaucoma is mainly associated with factors like age, ethnicity, and certain medical conditions, rather than a specific visual acuity measurement. Therefore, 20/80 vision is not a risk factor for glaucoma, making it the correct answer. The other choices, such as age, Mexican-American heritage, and elevated blood pressure, are established risk factors for developing glaucoma, as they are associated with an increased likelihood of the condition.

2. Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?

• A. 0.9% sodium chloride
• B. 5% dextrose in water solution
• C. Sterile water
• D. Heparin sodium

Correct answer: A

Rationale: The correct answer is 0.9% sodium chloride. Normal saline is 0.9% sodium chloride, which has the same osmolarity as blood and does not cause cell lysis. Choices 2 and 3, 5% dextrose in water solution and sterile water, are hypotonic solutions that can lead to cell lysis. Choice 4, heparin sodium, is an anticoagulant and is not used for flushing IV devices before and after blood administration.

3. The LPN is caring for a client admitted for acute pancreatitis. Which of these medications would be the least appropriate for pain management?

• A. Tylenol
• B. Tramadol
• C. Codeine
• D. Morphine

Correct answer: D

Rationale: Morphine is the least appropriate choice for pain management in pancreatitis due to its potential to cause spasms in the Sphincter of Oddi, which can worsen the client's condition by potentially obstructing the pancreatic duct. Tylenol, Tramadol, and Codeine are more suitable options for pain management in acute pancreatitis as they do not carry the same risk of exacerbating the condition by causing spasms in the Sphincter of Oddi.

4. A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expect to note if the bladder is full?

• A. Dull sounds
• B. Hyperresonance sounds
• C. Hypoactive bowel sounds
• D. An absence of bowel sounds

Correct answer: A

Rationale: When percussing a full bladder, the nurse expects to note dull sounds over the symphysis pubis. This is because a full bladder produces a flat or dull sound. Hyperresonance sounds are present with gaseous distention of the abdomen, not a full bladder. Bowel sounds are auscultated, not percussed, so hypoactive bowel sounds or an absence of bowel sounds are unrelated findings when assessing bladder distention.

5. When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?

• A. nausea and vomiting
• B. itching
• C. urinary retention
• D. somnolence

Correct answer: B

Rationale: A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4-7 hours after injection. While urinary retention is a side effect of postpartum epidural morphine, it is not typically assessed within the first 3 hours. Somnolence is a rare side effect and not commonly observed within the first 3 hours. Therefore, itching is the most likely side effect to be observed within the initial 3 hours after administering postpartum epidural morphine.

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