Nursing Elites

1. A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia?

• A. Linear clusters of vesicles on the right shoulder.
• B. Purulent drainage from both eyes.
• C. Decreased white blood cell count.
• D. Report of continued pain following resolution of the rash.

Correct answer: D

Rationale: The correct answer is D: Report of continued pain following resolution of the rash. Postherpetic neuralgia is a complication of herpes zoster characterized by persistent pain that continues even after the rash has resolved. This pain can be severe and debilitating, affecting the quality of life of the individual. Choices A, B, and C are incorrect because linear clusters of vesicles on the right shoulder would suggest an active herpes zoster outbreak, purulent drainage from both eyes would indicate an eye infection unrelated to postherpetic neuralgia, and a decreased white blood cell count is not typically associated with postherpetic neuralgia.

2. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

• A. Airway
• B. Blood pressure
• C. Surgical site
• D. Level of consciousness

Correct answer: A

Rationale: The correct answer is to assess the airway first. Ensuring a clear and patent airway is crucial to maintaining adequate oxygenation and ventilation post-surgery. Assessing the airway takes precedence over other assessments as a compromised airway can lead to hypoxia and respiratory distress. Checking blood pressure, the surgical site, or level of consciousness are important but are secondary to ensuring the airway is clear and the client can breathe effectively.

3. A client is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

• A. Ask the client to consider a direct donation
• B. Withhold the blood transfusion
• C. Request a consultation with the ethics committee
• D. Ask the client's family to intervene

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to withhold the blood transfusion. The principle of autonomy ensures that a competent client has the right to refuse treatment, even if their decision conflicts with the wishes of their partner or family. Asking the client to consider a direct donation (Choice A) is not appropriate as it disregards the client's autonomy and religious beliefs. Requesting a consultation with the ethics committee (Choice C) may be considered in complex ethical dilemmas, but in this case, the client's autonomy should be respected first. Asking the client's family to intervene (Choice D) is not appropriate as the client has the right to make their own healthcare decisions based on their religious beliefs.

4. What is the most important assessment for the LPN/LVN to perform on a client with a history of chronic obstructive pulmonary disease (COPD) receiving oxygen therapy at 2 liters per minute via nasal cannula?

• A. Assess the client's respiratory rate and effort.
• B. Measure the client's oxygen saturation level.
• C. Monitor the client's arterial blood gas levels.
• D. Check the client's blood pressure.

Correct answer: B

Rationale: Measuring the client's oxygen saturation level is the most important assessment in this scenario. Oxygen saturation level reflects how well the client is oxygenating, which is crucial in assessing the effectiveness of oxygen therapy for a client with COPD. Monitoring the respiratory rate and effort (Choice A) is important but assessing oxygenation with saturation levels takes precedence. While arterial blood gas levels (Choice C) provide comprehensive information, checking oxygen saturation is a quicker and more immediate way to assess oxygenation status. Checking blood pressure (Choice D) is not the priority when evaluating the effectiveness of oxygen therapy in COPD.

5. A healthcare professional is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the professional obtain to assess for this condition?

• A. Thermometer
• B. Elastic stockings
• C. Blood pressure cuff
• D. Sequential compression devices

Correct answer: C

Rationale: To assess for orthostatic hypotension, a healthcare professional needs to obtain a blood pressure cuff. Orthostatic hypotension is defined as a drop in blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure when moving from lying down to a standing position. A thermometer (Choice A) is used to measure body temperature and is not directly related to assessing orthostatic hypotension. Elastic stockings (Choice B) are used for preventing deep vein thrombosis and improving circulation in the lower extremities, not for assessing orthostatic hypotension. Sequential compression devices (Choice D) are mechanical pumps that are used to prevent deep vein thrombosis and are not specifically used for assessing orthostatic hypotension.

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