Nursing Elites

1. A client has been admitted to the hospital with severe diarrhea. The nurse should monitor the client for which complication?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: Severe diarrhea can lead to metabolic acidosis due to the loss of bicarbonate. When there is excessive loss of bicarbonate through diarrhea, the pH of the blood decreases, leading to metabolic acidosis. Metabolic alkalosis (Choice B) is not typically associated with severe diarrhea as it involves elevated pH and bicarbonate levels. Hyperkalemia (Choice C) is less likely with severe diarrhea as potassium is often lost along with fluids. Hypercalcemia (Choice D) is not a common complication of severe diarrhea; instead, hypocalcemia may occur due to malabsorption of calcium.

2. A client is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take?

• A. Contact the hospital’s spiritual services.
• B. Ask what is making the client cry.
• C. Ensure no visitors or staff enter the room for a short time period.
• D. Turn on the television for a distraction.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to ensure no visitors or staff enter the room for a short time period. Respecting the client's wish for privacy during emotional moments is crucial for providing patient-centered care. Contacting spiritual services or asking about the reason for crying may intrude on the client's privacy and emotional space. Turning on the television for a distraction is not appropriate as it does not address the client's emotional needs or request for privacy.

3. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B: 'Glasgow Coma Scale 8, respirations regular.' A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deep state of unconsciousness, which may not be accurate in this case. Choice C is incorrect as stating the client 'appears to be sleeping' may not accurately reflect the severity of the situation. Choice D is incorrect because a Glasgow Coma Scale of 13 would not typically correspond to a non-responsive state.

4. A client with a history of peptic ulcer disease reports black, tarry stools. What is the most appropriate action for the LPN/LVN to take?

• A. Reassure the client that this is not a normal finding.
• B. Notify the healthcare provider immediately.
• C. Document the finding in the client’s chart.
• D. Encourage the client to seek medical attention.

Correct answer: B

Rationale: The correct answer is B: Notify the healthcare provider immediately. Black, tarry stools can be indicative of gastrointestinal bleeding, a serious complication that requires urgent medical evaluation and intervention. This finding should not be dismissed or considered normal without further assessment. Option A is incorrect because black, tarry stools are not a normal finding and may signify a significant health issue. Option C is incorrect as immediate action is needed rather than just documenting the finding. Option D is not the best choice as it simply suggests seeking medical attention without emphasizing the urgency of the situation. Prompt notification of the healthcare provider is crucial to ensure timely intervention and management of potential gastrointestinal bleeding.

5. During a family assessment, a nurse is interviewing a family composed of a husband, a wife, and three children. One child is biological from this marriage, and the other two are from the wife’s previous marriage. How should the nurse identify this family form?

• A. Extended
• B. Blended
• C. Nuclear
• D. Alternative

Correct answer: B

Rationale: The correct answer is 'Blended.' This family is considered a blended family because it consists of children from previous marriages, along with the biological child of the current marriage. Choice A ('Extended') refers to a family that includes relatives beyond the nuclear family, such as grandparents or aunts/uncles. Choice C ('Nuclear') typically consists of a husband, wife, and their biological children only. Choice D ('Alternative') does not accurately describe the family structure presented in the scenario.

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