Nursing Elites

1. A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding 'stronger pain medications.' What initial action is most important for the LPN/LVN to take?

• A. Ask about any past history of drug abuse or addiction.
• B. Measure the pulse volume and capillary refill distal to the infiltration.
• C. Compress the infiltrated tissue to measure the degree of edema.
• D. Evaluate the extent of ecchymosis over the forearm area.

Correct answer: B

Rationale: The most important initial action for the LPN/LVN to take in this situation is to measure the pulse volume and capillary refill distal to the infiltration. This assessment helps evaluate the severity of the infiltration and the circulation in the affected arm. Asking about past history of drug abuse or addiction (Choice A) is not the priority when addressing acute arm pain and infiltration. Compressing the infiltrated tissue (Choice C) may exacerbate the pain and is not recommended as the first step. Evaluating the extent of ecchymosis (Choice D) is not as critical as assessing the circulation in the affected arm, which is better addressed by measuring pulse volume and capillary refill.

2. Why should a client with an ileal conduit be instructed to empty the collection device frequently?

• A. Force urine to back up into the kidneys.
• B. Suppress production of urine.
• C. Cause the device to pull away from the skin.
• D. Tear the ileal conduit

Correct answer: C

Rationale: A full urine collection bag can cause the device to pull away from the skin, leading to potential leakage and skin irritation. Choice A is incorrect because a full urine collection bag does not force urine to back up into the kidneys. Choice B is incorrect as a full collection bag does not suppress the production of urine. Choice D is incorrect as a full collection bag is unlikely to tear the ileal conduit.

3. The nurse is providing care for a client with a wound infection. Which type of precautions should the nurse implement?

• A. Airborne precautions
• B. Droplet precautions
• C. Contact precautions
• D. Standard precautions

Correct answer: C

Rationale: Contact precautions are necessary when caring for a client with a wound infection to prevent the spread of infection. Contact precautions involve practices such as wearing gloves and gowns, and ensuring proper hand hygiene. Airborne precautions are for diseases transmitted by small droplet nuclei that can remain suspended in the air, like tuberculosis. Droplet precautions are for diseases transmitted through respiratory droplets larger than 5 microns, such as influenza. Standard precautions are used for all clients to prevent the spread of infection and include practices like hand hygiene, use of personal protective equipment, and safe injection practices. In this case, since the client has a wound infection, the nurse should focus on implementing contact precautions to reduce the risk of spreading the infection to themselves or others.

4. A healthcare provider in an office is preparing to auscultate and percuss a client’s thorax as part of a comprehensive physical examination. Which of the following findings should the provider expect?

• A. Rhonchi
• B. Crackles
• C. Resonance
• D. Tactile fremitus

Correct answer: C

Rationale: During a thoracic examination, normal findings should include resonance, which is the expected sound when percussing the thorax. Resonance indicates healthy lung tissue and air-filled spaces. Abnormal findings such as rhonchi and crackles suggest issues like lung congestion or inflammation. Tactile fremitus refers to vibrations felt on the chest wall during palpation and is not typically assessed during percussion and auscultation of the thorax.

5. A client is admitted with a diagnosis of septicemia. Which assessment finding should the LPN/LVN report to the healthcare provider immediately?

• A. Increased urine output
• B. Decreased blood pressure
• C. Increased heart rate
• D. Increased respiratory rate

Correct answer: B

Rationale: In a client with septicemia, decreased blood pressure is a critical finding that suggests potential septic shock, a life-threatening condition. Septic shock requires immediate medical intervention to prevent further deterioration and organ dysfunction. Increased urine output (Choice A) may indicate adequate fluid resuscitation, which is a positive response. Increased heart rate (Choice C) and increased respiratory rate (Choice D) are common physiological responses to sepsis and do not necessarily indicate immediate life-threatening complications like decreased blood pressure does in septic shock.

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