Nursing Elites

1. A client's readiness to learn about insulin administration is being assessed by a nurse. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

• A. ''I can concentrate best in the morning.''
• B. ''It is difficult to read the instructions because my glasses are at home.''
• C. ''I'm wondering why I need to learn this.''
• D. ''You will have to talk to my wife about this.''

Correct answer: A

Rationale: Choice A is the correct answer because the client's statement about the best time to concentrate indicates readiness for learning. This statement shows an awareness and interest in learning. Choice B is incorrect as it indicates a barrier to learning due to not having glasses. Choice C is incorrect as it shows a lack of understanding or motivation for learning. Choice D is incorrect as it suggests a lack of personal involvement or responsibility in the learning process since the client is deflecting the responsibility to someone else.

2. A client with a history of peptic ulcer disease reports black, tarry stools. What is the most appropriate action for the LPN/LVN to take?

• A. Reassure the client that this is not a normal finding.
• B. Notify the healthcare provider immediately.
• C. Document the finding in the client’s chart.
• D. Encourage the client to seek medical attention.

Correct answer: B

Rationale: The correct answer is B: Notify the healthcare provider immediately. Black, tarry stools can be indicative of gastrointestinal bleeding, a serious complication that requires urgent medical evaluation and intervention. This finding should not be dismissed or considered normal without further assessment. Option A is incorrect because black, tarry stools are not a normal finding and may signify a significant health issue. Option C is incorrect as immediate action is needed rather than just documenting the finding. Option D is not the best choice as it simply suggests seeking medical attention without emphasizing the urgency of the situation. Prompt notification of the healthcare provider is crucial to ensure timely intervention and management of potential gastrointestinal bleeding.

3. A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client?

• A. “Get up and change positions slowly.”
• B. “Avoid eating aged cheese and smoked meat.”
• C. “Report any unusual bruising or bleeding to the doctor immediately.”
• D. “Eat the same amount of foods that contain vitamin K every day.”

Correct answer: A

Rationale: The correct instruction for the nurse to give the client who is starting on antihypertensive medication is to 'Get up and change positions slowly.' Antihypertensive medications can cause orthostatic hypotension, a drop in blood pressure when changing positions, so changing positions slowly helps prevent this adverse effect. Choice B about avoiding aged cheese and smoked meat is more relevant for clients taking monoamine oxidase inhibitors (MAOIs) due to potential interactions. Choice C regarding reporting unusual bruising or bleeding is more applicable for clients on anticoagulants. Choice D about consuming consistent amounts of vitamin K-containing foods daily is important for clients taking warfarin, not antihypertensive medications.

4. While caring for a client receiving parenteral fluid therapy via a peripheral IV catheter, after which of the following observations should the nurse remove the IV catheter?

• A. Swelling and coolness are observed at the IV site.
• B. The client reports mild discomfort at the insertion site.
• C. The infusion rate is slower than expected.
• D. The IV catheter is no longer needed for treatment.

Correct answer: A

Rationale: Swelling and coolness at the IV site can indicate complications such as infiltration, which can lead to tissue damage or fluid leakage into the surrounding tissues. Prompt removal of the IV catheter is essential to prevent further complications. The client reporting mild discomfort at the insertion site is common during IV therapy and does not necessarily warrant catheter removal unless there are signs of infiltration. A slower than expected infusion rate may not always necessitate IV catheter removal; the nurse should troubleshoot potential causes such as kinks in the tubing or pump malfunctions first. Just because the IV catheter is no longer needed for treatment does not automatically mean it should be removed; proper assessment and monitoring for complications are still essential.

5. A client is still experiencing mild back pain after receiving analgesia 1 hour ago. Which of the following nonpharmacological pain management techniques should the nurse include in the plan?

• A. Encourage the client to apply a heating pad for 2 hours at a time
• B. Apply an ice pack to the client’s back for 1 hour
• C. Remove distractions from the client’s room
• D. Instruct the client to take deep, rhythmic breaths

Correct answer: D

Rationale: In this scenario, the nurse should instruct the client to take deep, rhythmic breaths as a nonpharmacological pain management technique. Deep, rhythmic breathing helps with relaxation and pain management, potentially reducing the perception of pain. Encouraging the client to apply a heating pad for 2 hours at a time (Choice A) is not recommended as prolonged heat application can lead to tissue damage and is not suitable for mild back pain. Applying an ice pack for 1 hour (Choice B) may not be appropriate for mild back pain as cold therapy is more commonly used for acute injuries. Removing distractions from the client’s room (Choice C) may help create a more calming environment, but it does not directly address the client's pain.

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