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 in the emergency department is being cared for by a nurse and has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

• A. Tachycardia
• B. Elevated blood pressure
• C. Warm, dry skin
• D. Decreased respiratory rate

Correct answer: A

Rationale: Tachycardia is a hallmark sign of hypovolemic shock. When a client experiences significant blood loss, the body compensates by increasing the heart rate to maintain adequate perfusion to vital organs. Elevated blood pressure is not typically seen in hypovolemic shock; instead, hypotension is a more common finding. Warm, dry skin is characteristic of neurogenic shock, not hypovolemic shock. Decreased respiratory rate is not a typical manifestation of hypovolemic shock, as the body usually tries to increase respiratory effort to improve oxygenation in response to hypovolemia.

3. A client with a fractured femur has a BP of 140/94 mmHg and denies any history of HTN. Which of the following actions should the nurse take first?

• A. Request a prescription for an antihypertensive medication.
• B. Ask the client if they are having pain.
• C. Request a prescription for an antianxiety medication.
• D. Return in 30 minutes to recheck the client’s BP.

Correct answer: B

Rationale: The correct action is to ask the client if they are having pain. Pain can lead to temporary increases in blood pressure. Addressing pain as a potential cause is the initial step before considering medication adjustments. Requesting an antihypertensive medication or an antianxiety medication without assessing pain first would not address the immediate concern. Returning to recheck the BP can be done after addressing the potential pain issue.

4. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is MOST critical for the nurse to include in the plan of care?

• A. Hourly urine output
• B. White blood cell count
• C. Blood glucose every 4 hours
• D. Temperature every 2 hours

Correct answer: A

Rationale: Monitoring hourly urine output is crucial after successful resuscitation from a pulseless dysrhythmia to assess kidney function and perfusion. The kidneys are particularly vulnerable to injury following cardiac events due to decreased perfusion during the event. Evaluating urine output hourly allows for early detection of renal impairment or inadequate organ perfusion. Option B, monitoring white blood cell count, is not a priority in this situation as it does not directly relate to immediate post-resuscitation care. Option C, checking blood glucose every 4 hours, is important but not as critical as assessing kidney function and perfusion. Option D, measuring temperature every 2 hours, is relevant for monitoring signs of infection or inflammatory response but is not as crucial as assessing kidney function in this scenario.

5. A nurse at an assisted living facility is preparing an in-service for residents about electrical safety. Which of the following instructions should the nurse include?

• A. Avoid taping electrical cords to the floor.
• B. Clean electrical equipment before disconnection.
• C. Cover exposed wires with tape before use.
• D. Disconnect electrical equipment by grasping the plug.

Correct answer: A

Rationale: The correct instruction for electrical safety is to avoid taping electrical cords to the floor. Taping cords can create tripping hazards, leading to falls and potential injuries. Choice B, cleaning electrical equipment before disconnection, is not directly related to electrical safety but rather to equipment maintenance. Choice C, covering exposed wires with tape before use, is incorrect as exposed wires should be properly insulated and repaired by a qualified professional. Choice D, disconnecting electrical equipment by grasping the plug, is unsafe and can lead to electrical shocks. It is always recommended to unplug devices by holding the plug itself, not by pulling the cord.

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