Nursing Elites

1. A client with a history of hypertension is prescribed a beta-blocker. Which side effect should the LPN/LVN monitor for in this client?

• A. Increased appetite
• B. Dry mouth
• C. Bradycardia
• D. Insomnia

Correct answer: C

Rationale: The correct side effect that the LPN/LVN should monitor for in a client prescribed a beta-blocker is bradycardia. Beta-blockers work by slowing down the heart rate, which can lead to bradycardia as a common side effect. Monitoring the client's heart rate is crucial, as bradycardia can be a serious condition. Choices A, B, and D are incorrect because increased appetite, dry mouth, and insomnia are not typically associated with beta-blockers. Increased appetite is more commonly linked to certain medications like corticosteroids, dry mouth can be a side effect of anticholinergic medications, and insomnia may be a side effect of stimulant medications.

2. A client with limited mobility in his lower extremities is being cared for by a nurse. Which of the following actions should the nurse take to prevent skin breakdown?

• A. Place the client in high-Fowler's position
• B. Increase the client's intake of carbohydrates
• C. Massage the reddened areas with unscented lotion
• D. Have the client use a trapeze bar when changing positions

Correct answer: D

Rationale: The correct answer is to have the client use a trapeze bar when changing positions. This action helps in repositioning without causing friction or shearing, which can lead to skin breakdown. Placing the client in high-Fowler's position (Choice A) may not directly prevent skin breakdown related to limited mobility. Increasing carbohydrate intake (Choice B) is not relevant to preventing skin breakdown. Massaging reddened areas with lotion (Choice C) can potentially cause more harm by increasing friction and damaging the skin further, rather than preventing breakdown.

3. What intervention is most important for the LPN/LVN to implement for a male client experiencing urinary retention?

• A. Apply a condom catheter.
• B. Apply a skin protectant.
• C. Encourage increased fluid intake.
• D. Assess for bladder distention.

Correct answer: D

Rationale: The most important intervention for the LPN/LVN to implement for a male client experiencing urinary retention is to assess for bladder distention. This assessment is crucial as it helps identify the underlying cause of urinary retention, such as bladder distention or obstruction. By assessing the bladder, the LPN/LVN can determine the appropriate interventions needed, such as catheterization, medication administration, or further evaluation by the healthcare provider. Applying a condom catheter (Choice A) is more suitable for urinary incontinence, not retention. Applying a skin protectant (Choice B) is typically done to prevent skin breakdown in incontinent clients. Encouraging increased fluid intake (Choice C) may be beneficial for some urinary issues but is not the priority intervention for urinary retention.

4. A client is about to undergo emergency abdominal surgery for appendicitis. A healthcare professional is demonstrating postoperative deep breathing and coughing exercises to the client. The healthcare professional realizes the client may be unprepared to learn if the client:

• A. Is not feeling well
• B. Reports severe pain
• C. Has low blood pressure
• D. Is anxious

Correct answer: B

Rationale: Severe pain can be a significant distraction and impediment to the learning process. When a client is experiencing severe pain, their focus and attention are primarily directed towards managing the pain, making it difficult for them to absorb and retain new information effectively. Options A, C, and D, although important considerations in a healthcare setting, do not directly impact the client’s ability to learn in the same way that severe pain does. Not feeling well, low blood pressure, and anxiety are all factors that can be addressed or managed to facilitate learning, unlike severe pain which can significantly hinder the learning process.

5. When measuring a client's blood pressure, which approach is the priority for a nurse caring for a client with hypertension?

• A. Obtain the blood pressure under the same conditions each time
• B. Use a different arm for each measurement
• C. Measure the blood pressure while the client is standing
• D. Take multiple readings at different times of the day

Correct answer: A

Rationale: The correct approach when measuring a client's blood pressure, especially for a client with hypertension, is to obtain the blood pressure under the same conditions each time. Consistency in measurement conditions helps ensure accurate and comparable blood pressure readings. Using a different arm for each measurement (Choice B) is not ideal as it can lead to variations in readings. Measuring the blood pressure while the client is standing (Choice C) is not the standard practice and may not provide accurate results. Taking multiple readings at different times of the day (Choice D) may be useful for monitoring blood pressure trends but is not the priority when ensuring accurate individual readings.

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