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 client with a terminal illness and approaching death has noisy respirations and is short of breath. Which of the following actions should the nurse take?

• A. Elevate the head of the client's bed
• B. Administer an opioid medication
• C. Perform oral suctioning
• D. Place the client in a prone position

Correct answer: A

Rationale: Elevating the head of the client's bed is the most appropriate action in this situation. It helps reduce noisy respirations and improves comfort for clients with terminal illnesses by facilitating better air exchange. Administering an opioid medication may not address the immediate issue of noisy respirations and shortness of breath caused by secretions in the airway. Performing oral suctioning without proper assessment and indication can be uncomfortable for the client and may not be necessary. Placing the client in a prone position can further compromise breathing and is not recommended for a client with respiratory distress.

3. A client appears upset about the IV catheter insertion but does not communicate it to the nurse after being informed about the prescribed IV fluids. Which of the following is an appropriate nursing response?

• A. Ignore the client’s discomfort
• B. Reassure the client without addressing concerns
• C. Is there something about this procedure that concerns you?
• D. Proceed with the procedure

Correct answer: C

Rationale: The appropriate nursing response in this situation is to ask the client if there are any concerns about the procedure. By doing so, the nurse acknowledges the client's distress and opens up a dialogue to address any anxieties or misconceptions. Option A is incorrect as ignoring the client’s discomfort can lead to increased anxiety and potential harm. Option B is not ideal as reassuring the client without addressing specific concerns may not alleviate the client's distress. Option D is incorrect because proceeding with the procedure without addressing the client's unspoken concerns can further escalate the client's distress.

4. A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take?

• A. Perform deep palpation at the end of the admission assessment
• B. Auscultate the client’s abdomen before palpation
• C. Begin palpation of the abdomen at the site of pain
• D. Assess the client’s bowel sounds using the bell of the stethoscope

Correct answer: B

Rationale: Auscultating the abdomen before palpation is the correct action for the nurse to take in this scenario. This approach helps to assess bowel sounds accurately and prevents the alteration of bowel sounds that can occur due to palpation. By auscultating first, the nurse can gather important information about bowel function before proceeding with the palpation. Choice A is incorrect because deep palpation should be avoided initially, especially in a client reporting abdominal pain, as it may cause discomfort or potential harm. Choice C is incorrect as palpation should typically start away from the site of pain to prevent exacerbating discomfort. Choice D is incorrect because assessing bowel sounds with the bell of the stethoscope is not the initial step recommended when a client reports abdominal pain; auscultation should be performed with the diaphragm of the stethoscope first.

5. Postoperatively, signs of hemorrhagic shock are observed. The nurse notifies the surgeon, who instructs to continue monitoring vitals every 15 minutes and report back in one hour. What should the nurse do next?

• A. Notify the nurse manager
• B. Continue monitoring as instructed
• C. Administer IV fluids as per protocol
• D. Prepare for immediate transfer to the ICU

Correct answer: B

Rationale: The correct answer is to continue monitoring the patient as instructed. This is crucial to assess the patient's condition and response to initial interventions. Administering IV fluids or preparing for transfer to the ICU should only be done based on further assessment or explicit orders from the healthcare provider. Notifying the nurse manager, as suggested in choice A, without further assessment or intervention could delay immediate patient care and management.

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