Nursing Elites

1. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glascow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glascow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B. When documenting a client in a non-responsive state with stable vital signs and independent breathing, the nurse should document the Glasgow Coma Scale score to assess the level of consciousness and the regularity of respirations. Choice A is incorrect because 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as it does not provide a specific assessment like the Glasgow Coma Scale score. Choice D is incorrect as a Glasgow Coma Scale score of 13 indicates a more alert state than described in the scenario.

2. What action should the nurse include in the plan of care for a postoperative client with a history of poor nutritional intake who needs care for wound healing?

• A. Provide a protein intake of 1.5 g/kg of body weight per day.
• B. Increase carbohydrate intake to 50% of daily calories.
• C. Administer high-dose vitamin supplements.
• D. Ensure a daily intake of 1000 calories.

Correct answer: A

Rationale: To promote wound healing in a postoperative client with poor nutritional intake, the nurse should include a protein intake of 1.5 g/kg of body weight per day in the plan of care. Proteins are essential for tissue repair and wound healing. Increasing carbohydrate intake or administering high-dose vitamin supplements may not directly promote wound healing. Ensuring a daily intake of 1000 calories may not provide adequate nutrients for optimal wound healing.

3. A healthcare professional is preparing to perform denture care for a client. Which of the following actions should the professional plan to take?

• A. Pull down and out at the back of the upper denture to remove.
• B. Brush the dentures with a toothbrush and denture cleaner.
• C. Rinse the dentures with hot water after cleaning them.
• D. Place the dentures in a clean, dry storage container after cleaning them.

Correct answer: B

Rationale: The correct answer is to brush the dentures with a toothbrush and denture cleaner. This action ensures effective cleaning of the dentures. Dentures should be rinsed with cool or lukewarm water, not hot water, to prevent damage. Placing the dentures in a clean, dry storage container is not the immediate next step after cleaning; they should be kept moist to prevent warping.

4. A client with diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the LPN/LVN to take?

• A. Encourage the client to increase fluid intake.
• B. Monitor the client's blood glucose level.
• C. Administer insulin as prescribed.
• D. Assess the client's urine output.

Correct answer: B

Rationale: The correct answer is to monitor the client's blood glucose level. When a client with diabetes mellitus presents with symptoms of polyuria, polydipsia, and polyphagia, it indicates hyperglycemia. Monitoring blood glucose levels is crucial to assess and manage the client's condition effectively. Option A, encouraging the client to increase fluid intake, may exacerbate polyuria. Option C, administering insulin, should be done based on the healthcare provider's prescription after assessing the blood glucose level. Option D, assessing the client's urine output, is important but not the most immediate action needed in this scenario; monitoring blood glucose levels takes precedence.

5. A 16-year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?

• A. Ask the teenager to wait until a parent or legal guardian can be contacted
• B. Withhold treatment until telephone consent can be obtained from the partner
• C. Refer the teenager to a community pediatric hospital emergency department
• D. Proceed with the triage process in the same manner as any adult client

Correct answer: D

Rationale: The correct answer is to proceed with the triage process in the same manner as any adult client. In this scenario, since the teenager is legally married, they have the legal authority to consent to their own treatment. Choice A is incorrect because the teenager, being legally married, can provide their own consent. Choice B is incorrect as it unnecessarily delays treatment by waiting for telephone consent from the partner, which is not required in this case. Choice C is incorrect as the teenager can receive appropriate care in the current emergency department setting without the need for referral.

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