Nursing Elites

1. A nurse assisting with data collection uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse makes which determination?

• A. The client has a fever.
• B. The skin temperature is normal.
• C. The client needs to drink additional fluids.
• D. The client needs to have the blanket removed.

Correct answer: B

Rationale: To assess skin temperature, the nurse would first note the temperature of their own hands. Then, using the backs of the hands to palpate the client's skin bilaterally, warmth suggests normal circulatory status if the skin is warm and the temperature is equal bilaterally. The hands and feet may feel slightly cooler in a cool environment. Options A, C, and D are incorrect responses. A warm skin temperature does not indicate a fever, the need for additional fluids, or the need to have the blanket removed.

2. A client complains that her skin is redder than normal. The nurse notes the client's skin, documents hyperemia, and explains to the client that this condition is caused by which factor?

• A. Constriction of the underlying blood vessels
• B. An increased amount of bilirubin in the blood
• C. Increased perfusion of the surrounding tissues
• D. Excess blood in the dilated superficial capillaries

Correct answer: D

Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. Choice A is incorrect because constriction of blood vessels would lead to decreased blood flow, not excess blood. Choice B is incorrect as an increased amount of bilirubin in the blood is related to jaundice, not hyperemia. Choice C is incorrect because increased perfusion of the surrounding tissues would cause redness, not hyperemia.

3. The LPN is about to give 100 mg Lopressor (metoprolol) to a client. Before administering the drug, they take the patient's vitals, which are as follows: Pulse: 58 Blood Pressure: 90/62 Respirations: 18/minute What action should the LPN take?

• A. Give the client half the prescribed dose and report the findings to the RN on duty.
• B. Give the client double the dose and report the findings to the RN on duty.
• C. Administer the drug and report the findings to the RN on duty.
• D. Hold the drug and report the findings to the RN on duty.

Correct answer: D

Rationale: Lopressor is given to treat hypertension, and a pulse of 58 and a blood pressure of 90/62 are considered low. To prevent the client from bottoming out, the drug should be held, and the findings reported to the RN, who should consult with the attending physician. LPNs should never adjust client dosing, as that is outside of their scope of practice. It is crucial to follow facility guidelines, which often recommend holding blood pressure medication at 60 bpm and a systolic pressure of 90 or less. By holding the drug and notifying the RN, the LPN ensures the client's safety and allows for appropriate assessment and decision-making by the healthcare team. Giving half the dose or double the dose without proper authorization can lead to serious complications and is considered unsafe practice.

4. An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse makes which conclusion?

• A. The client has a low cardiac output.
• B. The client has a high cardiac output.
• C. The client has a normal cardiac output.
• D. The client will need a blood transfusion.

Correct answer: C

Rationale: A cardiac output of 5 L/min falls within the normal range for a resting adult, which typically ranges between 4 and 6 L/min. Cardiac output is calculated as the stroke volume (volume of blood in each systole) multiplied by the heart rate. Therefore, a cardiac output of 5 L/min is considered normal. Choices A and B are incorrect as they misinterpret the result as either low or high, which is not the case based on the provided information. Choice D is unrelated to the client's cardiac output and thus incorrect.

5. The client has an order for a 1,000 mL bag of fluids to be infused over 8 hours. What is the correct rate?

• A. 100 mL/hr
• B. 125 mL/min
• C. 125 mL/hr
• D. 80 mL/min

Correct answer: C

Rationale: To determine the correct infusion rate, divide the total volume of fluids (1,000 mL) by the total infusion time (8 hours), resulting in a rate of 125 mL/hr. This calculation ensures the appropriate administration of fluids over the specified time period. Choice A (100 mL/hr) is incorrect as it does not match the calculated rate based on the given information. Choice B (125 mL/min) is inaccurate because the question specifies the rate in hours, not minutes. Choice D (80 mL/min) is incorrect as it provides the rate in minutes rather than hours, which is the required unit for this scenario.

Similar Questions