Nursing Elites

1. A client, age 28, is 8 1/2 months pregnant. She is most likely to display which normal skin-color variation?

• A. vitiligo
• B. erythema
• C. cyanosis
• D. chloasma

Correct answer: D

Rationale: Chloasma, also known as the mask of pregnancy, is described as tan-to-brown patches on the face. This hyperpigmentation results from hormonal changes during pregnancy. Vitiligo is characterized by depigmented patches, erythema is redness of the skin due to increased blood flow, and cyanosis is a bluish discoloration due to poor circulation or lack of oxygen, none of which are typical skin-color variations during pregnancy. Therefore, in a pregnant client, the most likely normal skin-color variation to be displayed is chloasma.

2. A nurse assisting with data collection is preparing to auscultate for bowel sounds. The nurse should use which technique?

• A. Begin in the right lower quadrant.
• B. Use the bell end of the stethoscope.
• C. Hold the stethoscope lightly against the skin.
• D. Listen for at least 5 minutes before deciding that bowel sounds are absent.

Correct answer: A

Rationale: To auscultate for bowel sounds, the nurse should use the diaphragm end piece of the stethoscope as bowel sounds are relatively high pitched. The stethoscope should be held lightly against the skin to avoid stimulating more bowel sounds. The nurse should begin in the right lower quadrant at the ileocecal valve, where bowel sounds are normally present. It is recommended to listen for 5 minutes before deciding that bowel sounds are absent to ensure a thorough assessment. Choice B is incorrect because the bell end is used for low-pitched sounds such as heart sounds. Choice C is incorrect as holding the stethoscope firmly and deeply can cause unnecessary bowel sound stimulation. Choice D is incorrect as listening for 1 minute is insufficient to determine the presence or absence of bowel sounds.

3. While a client is on total parenteral nutrition, which of the following values should the nurse monitor closely?

• A. calcium
• B. magnesium
• C. glucose
• D. cholesterol

Correct answer: C

Rationale: Glucose should be monitored closely when a client is on total parenteral nutrition due to the high glucose concentration in the solutions. Monitoring glucose levels is crucial to prevent complications such as hyperglycemia or hypoglycemia. Calcium and magnesium are usually monitored to assess electrolyte imbalances, while cholesterol levels are not directly impacted by total parenteral nutrition. Therefore, choices A, B, and D are not the primary values that need close monitoring during total parenteral nutrition.

4. The nurse notes that a client in later adulthood has tremors of the hands. Based on this finding, what action should the nurse take?

• A. Ask the healthcare provider about referring the client to a neurological specialist.
• B. Obtain a prescription for a muscle relaxant.
• C. Notify the healthcare provider immediately.
• D. Document the findings.

Correct answer: D

Rationale: When a nurse observes senile tremors, such as intentional tremor of the hands in a client in later adulthood, it is important to document the findings. Senile tremors are benign and a normal age-related occurrence. Referring the client to a neurological specialist (Choice A) is unnecessary as senile tremors do not require specialized neurological intervention. Prescribing a muscle relaxant (Choice B) is not indicated since senile tremors are benign and not typically treated with muscle relaxants. Notifying the healthcare provider immediately (Choice C) is unnecessary as senile tremors do not require urgent intervention. Therefore, the most appropriate action is to document the findings (Choice D) for the client's medical record and to establish a baseline for future assessments.

5. The LPN has been asked to help a client taking Risperdal with activities of daily living in the morning. Which of these tasks is most likely to be potentially impacted by this medication?

• A. eating breakfast
• B. drinking fluids
• C. getting out of bed to use the bathroom
• D. brushing teeth

Correct answer: C

Rationale: The correct answer is 'getting out of bed to use the bathroom.' Risperdal can cause orthostatic hypotension, leading to a drop in blood pressure when changing positions from lying down to standing up. This effect increases the risk of falls, emphasizing the need to assist the client with this task to prevent potential harm. Choices A, B, and D are less likely to be directly impacted by the medication, unlike the significant risk of orthostatic hypotension associated with changing positions.

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