Nursing Elites

1. A client with a history of peptic ulcer disease is admitted with abdominal pain. Which finding should the LPN/LVN report to the healthcare provider immediately?

• A. Positive bowel sounds
• B. Rebound tenderness
• C. Increased appetite
• D. Elevated temperature

Correct answer: D

Rationale: Elevated temperature is the correct finding to report immediately in a client with a history of peptic ulcer disease and abdominal pain. This could indicate a perforation or worsening of the condition, requiring prompt medical attention. Positive bowel sounds (Choice A) are a normal finding and not a cause for concern. Rebound tenderness (Choice B) is concerning but does not require immediate attention compared to an elevated temperature. Increased appetite (Choice C) is not a red flag symptom for peptic ulcer disease and can be considered a positive sign, not requiring immediate attention.

2. A healthcare professional is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the healthcare professional identify as an indication that the treatment was successful?

• A. Increase in hematocrit
• B. Increase in respiratory rate
• C. Decrease in heart rate
• D. Decrease in capillary refill time

Correct answer: C

Rationale: Fluid-volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range. An increase in hematocrit (Choice A) would indicate hemoconcentration, not a successful fluid replacement. An increase in respiratory rate (Choice B) could indicate respiratory distress or hypoxia, not improvement in fluid volume status. A decrease in capillary refill time (Choice D) may indicate improved peripheral perfusion but is not a direct indicator of fluid replacement success.

3. A nurse in a surgical suite notes documentation on a client's medical record stating that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

• A. Ensure sterilization of non-disposable items with ethylene oxide
• B. Wrap monitoring cords with stockinette and secure them with non-latex tape
• C. Cleanse latex ports on IV tubing with chlorhexidine before administering medication
• D. Wear hypoallergenic latex gloves that are powder-free

Correct answer: B

Rationale: In this scenario, the nurse should take precautions to prevent latex exposure to the client due to his latex allergy. Wrapping monitoring cords with stockinette and securing them with non-latex tape helps to minimize the risk of latex contact with the client. Choice A is incorrect as sterilizing non-disposable items with ethylene oxide does not specifically address the avoidance of latex exposure. Choice C involves using latex ports on IV tubing, which can pose a risk of allergic reaction in a client with a latex allergy. Choice D suggests wearing latex gloves, even if hypoallergenic, which can still trigger a reaction in individuals with latex allergy. Therefore, the best option is to choose non-latex materials like stockinette and non-latex tape to prevent direct contact with latex.

4. A client is immobile due to a cast, and a nurse is assisting in the use of a fracture bedpan. Which of the following actions should the nurse take?

• A. Place the shallow end of the fracture pan under the client’s buttocks.
• B. Encourage the client to remain immobile on the fracture pan for 20 minutes.
• C. Keep the bed flat while the client is on the fracture pan.
• D. Hyperextend the client’s back while the fracture pan is in place.

Correct answer: A

Rationale: The correct action when using a fracture bedpan for an immobile client is to place the shallow end of the pan under the client's buttocks. This positioning helps in proper collection of feces without causing discomfort or injury. Encouraging the client to try to defecate for 20 minutes (Choice B) is inappropriate and unrealistic, as defecation should not be forced or timed. Keeping the bed flat (Choice C) is incorrect as elevating the head of the bed can help promote proper positioning for bedpan use. Hyperextending the client's back (Choice D) is contraindicated and can lead to discomfort and potential injury to the client.

5. A nursing assistive personnel (AP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?

• A. Not offering a backrub to a patient with fractured ribs
• B. Not offering to wash the hair of a patient with neck trauma
• C. Turning off the television while giving a backrub to the patient
• D. Turning the patient's head with neck injury to the side when giving oral care

Correct answer: D

Rationale: The correct answer is D. Turning a patient's head with a neck injury to the side when giving oral care can lead to harm or further injury. The neck should be kept in a neutral position to prevent exacerbation of the injury. Choices A, B, and C are not actions that require immediate nurse intervention. Not offering a backrub, not washing a patient's hair, or turning off the television are not critical issues that pose harm to the patient's well-being or safety.

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