Nursing Elites

1. A healthcare professional is admitting a client who has decreased circulation in his left leg. Which of the following actions should the healthcare professional take first?

• A. Evaluate pedal pulses
• B. Assess skin temperature
• C. Check for capillary refill
• D. Measure the leg circumference

Correct answer: A

Rationale: Evaluating pedal pulses should be the first action taken as it provides immediate information about circulation. This assessment helps in determining the adequacy of blood flow in the client's leg. Assessing skin temperature, checking for capillary refill, and measuring leg circumference are important assessments; however, evaluating pedal pulses is the most crucial initial step in this scenario. Skin temperature assessment and capillary refill check can provide additional valuable information about perfusion, while measuring leg circumference is useful in monitoring for edema. Therefore, for a client with decreased circulation in the left leg, evaluating pedal pulses takes precedence over the other assessments.

2. A 25-year-old primigravida at 16 weeks gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. Which nursing diagnosis should have the highest priority?

• A. Fluid volume deficit
• B. Altered nutrition: less than body requirements
• C. Anxiety related to new situational crisis
• D. Activity intolerance related to fatigue

Correct answer: A

Rationale: In a case of hyperemesis gravidarum, the priority nursing diagnosis should be addressing the Fluid volume deficit. This condition can lead to serious complications such as electrolyte imbalances and dehydration, which can endanger both the mother and the fetus if not managed promptly. Altered nutrition: less than body requirements is important but addressing the fluid volume deficit takes precedence as it poses an immediate threat. Anxiety related to new situational crisis and Activity intolerance related to fatigue are valid concerns, but they are secondary to the critical issue of fluid volume deficit in this scenario.

3. A client with type 1 diabetes mellitus is experiencing hypoglycemia. What is the best initial action for the LPN/LVN to take?

• A. Administer glucagon intramuscularly.
• B. Give the client 4 ounces of orange juice.
• C. Give the client a snack containing protein and carbohydrates.
• D. Encourage the client to rest until symptoms resolve.

Correct answer: B

Rationale: The best initial action for a client with type 1 diabetes mellitus experiencing hypoglycemia is to give them 4 ounces of orange juice. Orange juice quickly raises blood glucose levels in a hypoglycemic client. Administering glucagon intramuscularly is not the best initial action for hypoglycemia; it is usually reserved for severe hypoglycemia cases. Giving a snack containing protein and carbohydrates is not as rapid as orange juice in raising blood glucose levels during hypoglycemia. Encouraging the client to rest until symptoms resolve does not address the immediate need to raise blood glucose levels in a hypoglycemic state.

4. When explaining the procedure for collecting a 24-hour urine specimen for creatinine clearance to an older adult male, what should the nurse do next?

• A. Assess the client for confusion and reteach the procedure
• B. Check the urine for color and texture
• C. Empty the urinal contents into the 24-hour collection container
• D. Discard the contents of the urinal

Correct answer: A

Rationale: The correct next step for the nurse is to assess the client for confusion and reteach the procedure. This is crucial to ensure that the older adult male understands the process correctly, reducing the likelihood of errors in collecting the 24-hour urine specimen for creatinine clearance. Checking the urine for color and texture (Choice B) is not the immediate next step as the focus should be on patient understanding first. Emptying the urinal contents into the 24-hour collection container (Choice C) assumes prior knowledge on the client's part and skips the critical step of ensuring comprehension. Discarding the contents of the urinal (Choice D) is incorrect and wasteful since the urine is necessary for the 24-hour collection process.

5. A client who is postoperative and has paralytic ileus is being cared for by a nurse. Which of the following abdominal assessments should the nurse expect?

• A. Absent bowel sounds with distention
• B. Hyperactive bowel sounds
• C. Normal bowel sounds
• D. High-pitched bowel sounds

Correct answer: A

Rationale: In a client with paralytic ileus, absent bowel sounds with distention are expected due to decreased or absent bowel motility. This is a key characteristic of paralytic ileus, where the bowel is unable to contract and move contents along the digestive tract. Hyperactive bowel sounds (choice B) are more indicative of increased peristalsis, which is not typically seen in paralytic ileus. Normal bowel sounds (choice C) may not be present in a client with paralytic ileus. High-pitched bowel sounds (choice D) are not typically associated with paralytic ileus. Therefore, the correct assessment finding in this scenario is absent bowel sounds with distention.

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