Nursing Elites

1. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority?

• A. Pain related to ischemia
• B. Risk for altered elimination: constipation
• C. Risk for complication: dysrhythmias
• D. Anxiety related to pain

Correct answer: A

Rationale: The correct answer is A: Pain related to ischemia. This nursing diagnosis should have priority because addressing the pain caused by ischemia is crucial in managing the client's myocardial infarction. Pain management is essential not only for the client's comfort but also for improving outcomes and reducing complications. Choices B, C, and D are not the priority in this scenario. Risk for altered elimination: constipation (Choice B) is not as immediate a concern as managing the client's pain. Risk for complication: dysrhythmias (Choice C) may be a potential concern but addressing the client's pain takes precedence. Anxiety related to pain (Choice D) is important to address but should come after managing the pain itself.

2. A client with a history of deep vein thrombosis (DVT) is admitted with swelling and pain in the left leg. What is the most appropriate action for the LPN/LVN to take?

• A. Apply warm compresses to the affected leg.
• B. Elevate the left leg above the level of the heart.
• C. Measure the circumference of the left leg.
• D. Administer pain medication as prescribed.

Correct answer: C

Rationale: Measuring the circumference of the left leg is the most appropriate action for an LPN/LVN when assessing a client with a history of DVT and presenting with swelling and pain in the left leg. This measurement helps to assess the extent of swelling objectively and monitor changes in the client's condition. Applying warm compresses (Choice A) may worsen the condition by potentially promoting clot development. Elevating the left leg above the level of the heart (Choice B) is generally recommended for DVT to improve venous return, but measuring the circumference is more appropriate in this scenario. Administering pain medication (Choice D) does not address the underlying issue and should not be the initial action taken.

3. A client enters the emergency department unconscious via ambulance from the client's workplace. What document should be given priority to guide the direction of care for this client?

• A. The statement of client rights and the client self-determination act
• B. Orders written by the healthcare provider
• C. A notarized original of advance directives brought in by the partner
• D. The clinical pathway protocol of the agency and the emergency department

Correct answer: C

Rationale: In this scenario, when the client is unconscious and unable to make decisions, a notarized original of advance directives brought in by the partner should be given priority to guide the direction of care. Advance directives provide legal documentation of the client's wishes regarding healthcare decisions in situations where they cannot express their preferences. The statement of client rights and the client self-determination act (Choice A) outlines general principles but does not provide specific guidance on the client's care. Orders written by the healthcare provider (Choice B) are important but may not reflect the client's preferences. Clinical pathway protocols (Choice D) are useful for standard care pathways but do not address individual client wishes.

4. A client recovering from lung cancer is advised to resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?

• A. Washing dishes
• B. Mowing the lawn
• C. Carrying heavy groceries
• D. Gardening

Correct answer: A

Rationale: The correct answer is A: Washing dishes. Washing dishes is a lower-intensity activity that is suitable for a client recovering from lung cancer. This activity does not require significant physical exertion and allows the client to engage in a manageable task while still following the provider's instructions for lower-intensity activities. Choices B, C, and D involve more physical effort and may not be appropriate for a client recovering from lung cancer, as they require more energy and physical strain, which could hinder the recovery process.

5. A client who is malnourished expresses concern about losing their loose wedding ring. What is the most appropriate action for the nurse to take?

• A. I can pin it to your hospital gown to prevent it from falling off.
• B. I will place it in your drawer to keep it safe.
• C. I will hold onto it until a family member can retrieve it.
• D. I can put it in a locked storage unit for you.

Correct answer: D

Rationale: The most appropriate action for the nurse to take is to put the client's wedding ring in a locked storage unit for safekeeping. This ensures that the ring is secure and minimizes the risk of loss or damage. Choices A, B, and C do not provide the same level of security and protection as placing the ring in a locked storage unit. Pinning it to the hospital gown (Choice A) may not be secure and could still lead to loss. Placing it in the client's drawer (Choice B) may not guarantee its safety. Holding onto it until a family member retrieves it (Choice C) leaves the ring vulnerable to misplacement or theft.

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