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. A client requires gastric decompression, and a nurse is inserting an NG tube. Which action should the nurse take to verify proper placement of the tube?

• A. Assess the client for a gag reflex
• B. Measure the pH of the gastric aspirate
• C. Place the end of the NG tube in water to observe for bubbling
• D. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water

Correct answer: B

Rationale: Measuring the pH of the gastric aspirate is the most reliable method to confirm proper placement of an NG tube. Gastric fluid has an acidic pH, typically ranging from 1 to 5. Assessing the client for a gag reflex (choice A) is important for airway protection but does not confirm tube placement. Placing the NG tube in water to observe for bubbling (choice C) is incorrect and not a reliable method for verifying placement. Auscultating 2.5 cm above the umbilicus while injecting sterile water (choice D) is an outdated method and is not recommended for verifying NG tube placement.

3. A home health nurse is teaching a new caregiver how to care for a client who has had a tracheostomy for 1 year. Which of the following instructions should the nurse include?

• A. Use tracheostomy covers when going outdoors.
• B. Maintain sterile technique when performing tracheostomy care.
• C. Do not remove the outer cannula for routine cleaning.
• D. Clean around the stoma with normal saline.

Correct answer: A

Rationale: The correct answer is to use tracheostomy covers when going outdoors. This instruction is important as it helps protect the airway from dust and other particles, reducing the risk of infection or irritation. Choice B is incorrect because maintaining sterile technique is crucial during tracheostomy care to prevent infections, but it is not the most pertinent instruction in this scenario. Choice C is incorrect as removing the outer cannula is not a routine cleaning procedure and should only be done by healthcare professionals when necessary. Choice D is incorrect because cleaning around the stoma with normal saline is not recommended as it can cause irritation to the skin and stoma site.

4. A client is drawing up and mixing insulin under the observation of a nurse. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?

• A. The client is able to discuss the appropriate technique.
• B. The client is able to demonstrate the appropriate technique.
• C. The client states an understanding of the process.
• D. The client is able to write the steps on a piece of paper.

Correct answer: B

Rationale: The correct answer is B because the ability to demonstrate the appropriate technique shows that the client has acquired the psychomotor skills needed for insulin preparation. Merely discussing, stating an understanding, or writing the steps does not confirm that the client can physically perform the task correctly. Being able to demonstrate indicates practical application and mastery of the skill. Choice A is incorrect because discussing the technique does not necessarily mean the client can physically perform it. Choice C is incorrect as stating an understanding does not guarantee the client's ability to perform the task. Choice D is incorrect because writing the steps does not assess the client's physical execution of the technique.

5. A client is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

• A. Erythema along the path of the vein
• B. Pitting edema at the insertion site
• C. Coolness of the client’s left forearm
• D. Pallor of the client’s left forearm

Correct answer: A

Rationale: Erythema (redness) along the path of the vein is a classic sign of phlebitis, indicating inflammation of the vein. This occurs due to irritation or infection at the IV site. Pitting edema (choice B) is not typically associated with phlebitis but suggests fluid overload or poor circulation. Coolness (choice C) and pallor (choice D) of the forearm are not characteristic signs of phlebitis but may indicate impaired circulation or reduced blood flow to the area.

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