Nursing Elites

1. A client with a history of asthma is experiencing shortness of breath. What is the most appropriate action for the LPN/LVN to take first?

• A. Administer a bronchodilator as prescribed.
• B. Encourage the client to practice deep breathing exercises.
• C. Position the client in high Fowler's position.
• D. Obtain a peak flow reading.

Correct answer: A

Rationale: Administering a bronchodilator as prescribed is the most appropriate initial action for managing asthma-related shortness of breath. Bronchodilators help to open up the airways quickly, providing relief for the client. Encouraging deep breathing exercises may be beneficial in some situations but should not be the first action for acute shortness of breath in asthma. Positioning the client in high Fowler's position can also help improve breathing, but administering the bronchodilator takes precedence. Obtaining a peak flow reading is important in asthma management, but it is not the initial action needed to address acute shortness of breath.

2. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

• A. The AP hangs the collection bag below the level of the bladder.
• B. The AP performs hand hygiene before handling the catheter.
• C. The AP secures the catheter to the client’s leg with tape.
• D. The AP empties the collection bag when it is full.

Correct answer: A

Rationale: Hanging the collection bag below the level of the bladder is the correct technique for maintaining proper drainage and preventing backflow in a client with an indwelling urinary catheter. Therefore, choice A is the correct answer as it indicates a need for further teaching. Choices B, C, and D demonstrate appropriate actions in catheter care. Performing hand hygiene before handling the catheter helps prevent infection, securing the catheter to the client’s leg with tape prevents accidental dislodgement, and emptying the collection bag when it is full ensures that the catheter functions effectively.

3. A client with a history of heart failure presents with increased shortness of breath and swelling in the legs. What is the most important assessment for the LPN/LVN to perform?

• A. Monitor the client's oxygen saturation level.
• B. Assess the client's apical pulse.
• C. Check for jugular vein distention.
• D. Measure the client's urine output.

Correct answer: C

Rationale: Checking for jugular vein distention is crucial in assessing fluid overload in clients with heart failure. Jugular vein distention indicates increased central venous pressure, which can be a sign of worsening heart failure. Monitoring oxygen saturation (Choice A) is important but may not provide immediate information on fluid status. Assessing the apical pulse (Choice B) is relevant for monitoring heart rate but may not directly indicate fluid overload. Measuring urine output (Choice D) is essential for assessing renal function and fluid balance but does not provide immediate information on fluid overload in this scenario.

4. A client with a history of peptic ulcer disease is admitted with abdominal pain. Which finding should the LPN/LVN report to the healthcare provider immediately?

• A. Positive bowel sounds
• B. Rebound tenderness
• C. Increased appetite
• D. Elevated temperature

Correct answer: D

Rationale: Elevated temperature is the correct finding to report immediately in a client with a history of peptic ulcer disease and abdominal pain. This could indicate a perforation or worsening of the condition, requiring prompt medical attention. Positive bowel sounds (Choice A) are a normal finding and not a cause for concern. Rebound tenderness (Choice B) is concerning but does not require immediate attention compared to an elevated temperature. Increased appetite (Choice C) is not a red flag symptom for peptic ulcer disease and can be considered a positive sign, not requiring immediate attention.

5. 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 copy 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 the scenario described, when a client arrives unconscious, priority should be given to a notarized original copy of advance directives brought in by the partner. Advance directives are legal documents that specify a person's healthcare wishes and decision-making preferences in advance. These directives guide healthcare providers in delivering care according to the client's preferences when the client is unable to communicate. The statement of client rights and the client self-determination act (Choice A) are important but do not provide specific care instructions. Orders written by the healthcare provider (Choice B) may not reflect the client's wishes. Clinical pathway protocols (Choice D) are valuable but do not address the individualized care preferences of the client.

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