Nursing Elites

1. A client with a history of congestive heart failure (CHF) is admitted with dyspnea and a productive cough. What is the most important assessment for the LPN/LVN to perform?

• A. Measure the client's urine output.
• B. Auscultate the client's lung sounds.
• C. Assess the client's apical pulse.
• D. Check the client's blood pressure.

Correct answer: B

Rationale: Auscultating lung sounds is crucial for assessing the extent of congestion in a client with CHF. The presence of crackles or wheezing can indicate fluid accumulation in the lungs, a common complication of CHF. Monitoring urine output (Choice A) is important to assess renal function but is not the priority in this situation. While assessing the apical pulse (Choice C) and checking blood pressure (Choice D) are important in managing CHF, they do not provide immediate information about the respiratory status and congestion level in the lungs, making auscultating lung sounds the most critical assessment.

2. When admitting a client, what information should the nurse record in the client’s record first?

• A. Assessment of the client
• B. Client’s medical history
• C. Plan of care
• D. Vital signs

Correct answer: A

Rationale: When admitting a client, the nurse's first step should be to assess the client. Assessment is crucial as it helps establish a baseline of the client's condition, identify any immediate concerns, and guide the development of an individualized plan of care. Recording the client's medical history, plan of care, or vital signs may follow the initial assessment but are secondary to the primary assessment process.

3. The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials?

• A. Solid foods are introduced one at a time beginning with cereal.
• B. Finely ground meat should be avoided early to provide iron.
• C. Egg white is not recommended early to increase protein intake.
• D. Solid foods should not be mixed with formula in a bottle.

Correct answer: A

Rationale: The correct answer is A. Introducing solid foods one at a time, starting with cereal, is recommended to monitor for any food allergies or intolerances in infants. Choice B is incorrect as finely ground meat should be introduced later due to the risk of choking and is not necessary for iron intake. Choice C is incorrect as egg white should be avoided early due to the risk of allergies. Choice D is incorrect as solid foods should not be mixed with formula in a bottle to prevent overfeeding and promote healthy eating habits.

4. A client is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

• A. Reassure the client that this is an expected response to grief.
• B. Ignore the client’s anger and continue with the plan of care.
• C. Tell the client that anger is not going to help his situation.
• D. Encourage the client to express his anger.

Correct answer: A

Rationale: When a client is expressing anger about a diagnosis, it is essential for the nurse to validate the client's feelings. Choice A is correct because reassuring the client that anger is an expected response to grief acknowledges the client's emotions and encourages expression, fostering a therapeutic relationship. This validation helps the client feel understood and supported during a challenging time. Choice B is incorrect as ignoring the client's anger can lead to feelings of neglect and hinder effective communication, which is crucial for providing holistic care. Choice C is inappropriate because telling the client that anger is not helpful dismisses the client's emotions and can further escalate the situation, potentially damaging the nurse-client relationship. Choice D is not the best option as it does not involve acknowledging the client's feelings or providing support and validation, which are vital in promoting emotional well-being and trust between the client and the nurse.

5. The nurse is providing discharge teaching to a client who has been prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?

• A. I will avoid eating foods high in vitamin K.
• B. I will take my medication at the same time every day.
• C. I will use a soft toothbrush to prevent gum bleeding.
• D. I can take aspirin if I have a headache.

Correct answer: D

Rationale: The correct answer is D: 'I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or other medications that increase the risk of bleeding. Choices A, B, and C are correct statements that show understanding of warfarin therapy, such as the importance of avoiding foods high in vitamin K, taking medication consistently, and using a soft toothbrush to prevent gum bleeding.

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