Nursing Elites

1. What is the most important assessment for the LPN/LVN to perform on a client with a history of chronic obstructive pulmonary disease (COPD) receiving oxygen therapy at 2 liters per minute via nasal cannula?

• A. Assess the client's respiratory rate and effort.
• B. Measure the client's oxygen saturation level.
• C. Monitor the client's arterial blood gas levels.
• D. Check the client's blood pressure.

Correct answer: B

Rationale: Measuring the client's oxygen saturation level is the most important assessment in this scenario. Oxygen saturation level reflects how well the client is oxygenating, which is crucial in assessing the effectiveness of oxygen therapy for a client with COPD. Monitoring the respiratory rate and effort (Choice A) is important but assessing oxygenation with saturation levels takes precedence. While arterial blood gas levels (Choice C) provide comprehensive information, checking oxygen saturation is a quicker and more immediate way to assess oxygenation status. Checking blood pressure (Choice D) is not the priority when evaluating the effectiveness of oxygen therapy in COPD.

2. The client is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which finding indicates that the bladder irrigation is effective?

• A. The client reports minimal pain and discomfort.
• B. The urine appears clear and free of clots.
• C. The client has no signs of infection.
• D. The client is able to void independently.

Correct answer: B

Rationale: The presence of clear urine free of clots is an indicator that the bladder irrigation is effective. This finding suggests that the irrigation is preventing clot formation and ensuring proper drainage, which is crucial after a TURP procedure. The client reporting minimal pain and discomfort (choice A) may be a positive sign but does not directly reflect the effectiveness of the bladder irrigation. The absence of infection signs (choice C) is important but not specific to evaluating the bladder irrigation. The client being able to void independently (choice D) is a good sign overall but does not specifically indicate the effectiveness of the bladder irrigation.

3. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

• A. Airway
• B. Blood pressure
• C. Surgical site
• D. Level of consciousness

Correct answer: A

Rationale: The correct answer is to assess the airway first. Ensuring a clear and patent airway is crucial to maintaining adequate oxygenation and ventilation post-surgery. Assessing the airway takes precedence over other assessments as a compromised airway can lead to hypoxia and respiratory distress. Checking blood pressure, the surgical site, or level of consciousness are important but are secondary to ensuring the airway is clear and the client can breathe effectively.

4. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

• A. Perform hand hygiene
• B. Identify the client using two identifiers
• C. Prepare the sterile field
• D. Don sterile gloves

Correct answer: A

Rationale: Performing hand hygiene is essential before any direct patient care procedure to prevent the spread of infection. Proper hand hygiene helps reduce the risk of introducing harmful microorganisms to the client, especially when dealing with a procedure like tracheostomy care. Identifying the client, preparing the sterile field, and donning sterile gloves are all important steps in tracheostomy care, but hand hygiene precedes them to maintain asepsis and ensure patient safety.

5. A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following techniques should the nurse identify as indicating the correct method for eliciting the client's patellar reflex?

• A. Tap just below the knee
• B. Tap on the upper thigh
• C. Tap on the ankle
• D. Tap on the lower leg

Correct answer: A

Rationale: The correct technique for eliciting the client's patellar reflex is to tap just below the knee. This action stimulates the stretch receptors in the patellar tendon, leading to a reflex contraction of the quadriceps muscle and extension of the lower leg. Tapping on the upper thigh (Choice B) would not elicit the patellar reflex as it targets a different area. Similarly, tapping on the ankle (Choice C) or tapping on the lower leg (Choice D) would not produce the desired response associated with the patellar reflex, making them incorrect choices.

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