Nursing Elites

1. A client with a history of asthma presents to the emergency department with difficulty breathing and wheezing. Which of the following is the priority nursing action?

• A. Administer a bronchodilator
• B. Obtain a peak flow reading
• C. Provide supplemental oxygen
• D. Assess the client's respiratory rate

Correct answer: A

Rationale: In a client with a history of asthma experiencing difficulty breathing and wheezing, the priority nursing action is to administer a bronchodilator. This intervention helps relieve bronchospasm and improve the client's breathing. Obtaining a peak flow reading can provide additional information but is not the immediate priority in this situation. Providing supplemental oxygen may be needed but addressing the bronchospasm with a bronchodilator takes precedence. Assessing the client's respiratory rate is important but not as urgent as administering a bronchodilator to address the breathing difficulty.

2. A client is 6 hours postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?

• A. Allow the client to hear running water while attempting to void
• B. Provide the client with a bedpan while sitting upright
• C. Insert an indwelling urinary catheter and connect it to gravity drainage
• D. Encourage the client to limit fluid intake

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to allow the client to hear running water while attempting to void. This can help stimulate the urge to urinate in a non-invasive way, promoting natural voiding. Providing a bedpan while sitting upright is also a suitable approach to facilitate voiding by encouraging a more natural position. Inserting an indwelling urinary catheter should be a last resort due to infection risks and discomfort associated with catheterization. Encouraging the client to limit fluid intake is not appropriate as hydration is crucial for overall health and can aid in promoting voiding. Therefore, the best initial intervention to promote voiding in this scenario is to allow the client to hear running water.

3. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the LPN have for planning care in terms of the client's beliefs?

• A. Autopsy of the body is prohibited.
• B. Blood transfusions are forbidden.
• C. Alcohol use in any form is not allowed.
• D. A vegetarian diet must be followed.

Correct answer: B

Rationale: The correct answer is B: 'Blood transfusions are forbidden.' Jehovah's Witnesses typically refuse blood transfusions due to their religious beliefs. This is crucial for the LPN to consider when planning the client's care to ensure that alternative treatments are explored. Choices A, C, and D are incorrect as they do not align with the specific beliefs and practices of Jehovah's Witnesses. Autopsy prohibition, alcohol use restrictions, and dietary preferences are not primary concerns related to the religious beliefs of Jehovah's Witnesses.

4. A healthcare provider has inserted an indwelling catheter for a male patient. Where should the healthcare provider tape the catheter to prevent pressure on the client's urethra at the penoscrotal junction?

• A. Lower abdomen
• B. Upper thigh
• C. Penoscrotal junction
• D. Mid-abdomen

Correct answer: A

Rationale: Taping the catheter to the lower abdomen is the correct placement to prevent pressure on the urethra at the penoscrotal junction. Securing the catheter at the lower abdomen helps in reducing discomfort and minimizes the risk of trauma to the urethra. Placing the catheter on the upper thigh or penoscrotal junction can lead to tension on the catheter and potential discomfort for the patient. Taping the catheter to the mid-abdomen is not recommended as it does not provide the necessary support to prevent pressure on the urethra at the penoscrotal junction.

5. A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicated understanding?

• A. “I will set my water heater at 130°F.”
• B. “Once my baby can sit up, they should be safe in the bathtub.”
• C. “I will place my baby on their stomach to sleep.”
• D. “Once my infant starts to push up, I will remove the mobile from over the crib.”

Correct answer: D

Rationale: The correct answer is D. Removing the mobile when the baby starts to push up prevents choking hazards as infants can reach and grab objects posing a risk of choking. Choice A is unsafe as setting the water heater at 130°F can scald a child. Choice B is incorrect because even when a baby can sit up, they still require close supervision in the bathtub. Choice C is unsafe as current guidelines recommend placing babies on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS). Therefore, choices A, B, and C are incorrect or unsafe practices for infant care.

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