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. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B: 'Glasgow Coma Scale 8, respirations regular.' A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deep state of unconsciousness, which may not be accurate in this case. Choice C is incorrect as stating the client 'appears to be sleeping' may not accurately reflect the severity of the situation. Choice D is incorrect because a Glasgow Coma Scale of 13 would not typically correspond to a non-responsive state.

2. A nurse is collecting a blood pressure reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mmHg. Which of the following actions should the nurse take?

• A. Ensure that the width of the BP cuff is appropriate for the client's arm circumference.
• B. Reposition the client supine and recheck their BP.
• C. Recheck the client's BP and measure their other arm for comparison.
• D. Request that another nurse check the client's BP in 30 minutes.

Correct answer: C

Rationale: When a nurse obtains a blood pressure reading that is elevated, the appropriate action is to recheck the client's BP and measure the other arm for comparison. This step helps ensure accuracy by ruling out errors like improper cuff size, positioning, or equipment malfunction. Repositioning the client supine is not necessary unless the client shows signs of distress or symptoms. Ensuring the appropriate cuff width is important for accurate readings but does not address the immediate need to confirm the current BP. Requesting another nurse to check the BP in 30 minutes delays immediate action and does not address the need for verification and comparison of the current reading.

3. A healthcare provider is witnessing a client sign an informed consent form for surgery. Which of the following describes what the healthcare provider is affirming by this action?

• A. The signature on the preoperative consent form is the client’s
• B. The client understands the risks of the surgery
• C. The client is aware of all postoperative care instructions
• D. The client has no further questions about the surgery

Correct answer: A

Rationale: The correct answer is A. When a healthcare provider witnesses a client signing an informed consent form for surgery, they are affirming that the signature on the form belongs to the client. This is crucial for ensuring patient autonomy and informed decision-making. Choices B, C, and D are incorrect because while it is important for the client to understand the risks of surgery, be aware of postoperative care instructions, and have an opportunity to ask questions, these elements are not specifically affirmed by the healthcare provider witnessing the signature.

4. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which instruction should the LPN/LVN reinforce to the client to help manage their condition?

• A. Increase fluid intake to thin secretions.
• B. Practice pursed-lip breathing to improve oxygenation.
• C. Avoid physical activity to prevent dyspnea.
• D. Use a peak flow meter to monitor lung function.

Correct answer: B

Rationale: Practicing pursed-lip breathing is an essential technique to help manage COPD as it can improve oxygenation by promoting better gas exchange. This technique helps to keep the airways open longer during exhalation, preventing air trapping and improving breathing efficiency. Increasing fluid intake can help thin secretions, which is beneficial, but it is not the primary instruction for managing COPD. Avoiding physical activity is not recommended as it can lead to deconditioning and worsen dyspnea in COPD patients. Using a peak flow meter is more commonly associated with monitoring asthma rather than COPD, so it is not the most relevant instruction for managing COPD.

5. When performing nasotracheal suctioning on a client with a respiratory infection, what technique should be used?

• A. Apply intermittent suction when withdrawing the catheter.
• B. Apply continuous suction during insertion of the catheter.
• C. Apply suction only during insertion of the catheter.
• D. Insert the catheter while the client is exhaling.

Correct answer: A

Rationale: The correct technique for nasotracheal suctioning is to apply intermittent suction when withdrawing the catheter. This method helps prevent damage to the mucosa and is the recommended approach. Continuous suction during insertion (choice B) can cause trauma to the airway lining. Applying suction only during insertion (choice C) is not sufficient for effective removal of secretions. Inserting the catheter while the client is exhaling (choice D) does not follow the standard procedure for nasotracheal suctioning.

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