Nursing Elites

1. A client newly diagnosed with type 1 diabetes mellitus is resistant to learning self-injection of insulin and asks the nurse to administer all the injections. The nurse explains the importance of learning self-care and appropriately adds which of the following statement?

• A. Insulin injections are not difficult to learn.
• B. Tell me what I can do to help you overcome your fear of giving yourself injections.
• C. It’s important to learn self-care for future independence.
• D. You need to learn this for your health.

Correct answer: B

Rationale: Choice B is the correct answer because it addresses the client's fear and offers support to help them overcome the resistance to self-care. By expressing willingness to assist and asking for ways to help the client, the nurse encourages open communication and collaboration in finding solutions to the client's concerns. Choices A, C, and D, while valid statements, do not directly address the client's fear or resistance, which is crucial in promoting self-care adherence in this situation.

2. A client who is postoperative has paralytic ileus. Which of the following abdominal assessments should the nurse expect?

• A. Absent bowel sounds with distention
• B. Hyperactive bowel sounds with pain
• C. Normal bowel sounds with cramping
• D. Diminished bowel sounds with tenderness

Correct answer: A

Rationale: Paralytic ileus is a condition where there is a temporary paralysis of the bowel, leading to absent bowel sounds and abdominal distention. This occurs because the bowel is not functioning properly to propel contents, resulting in a lack of bowel sounds. Absent bowel sounds with distention are typical findings in paralytic ileus. Hyperactive bowel sounds with pain are more indicative of increased motility and are not expected in paralytic ileus. Normal bowel sounds with cramping may be seen in other conditions, such as gastroenteritis. Diminished bowel sounds with tenderness are not typical findings in paralytic ileus.

3. A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the LPN/LVN set the client's intravenous infusion pump?

• A. 13 ml/hour
• B. 63 ml/hour
• C. 80 ml/hour
• D. 125 ml/hour

Correct answer: B

Rationale: To calculate the correct rate of infusion, divide the total volume by the total time: 250 ml / 4 hours = 62.5 ml/hour, which is rounded up to 63 ml/hour. This rate ensures the proper administration of the KCl over the 4-hour period. Choice A (13 ml/hour) is incorrect as it does not match the calculated rate. Choices C (80 ml/hour) and D (125 ml/hour) are also incorrect as they do not correspond to the calculated rate needed for the specified time frame.

4. A mother tells the nurse that her 2-year-old toddler has temper tantrums and says 'no' every time the mother tries to help them get dressed. The nurse should recognize the toddler is manifesting which of the following stages of development?

• A. Trying to increase independence.
• B. Developing a sense of trust.
• C. Establishing a new identity.
• D. Attempting to master a skill.

Correct answer: A

Rationale: The correct answer is A: Trying to increase independence. Toddlers around the age of 2 often exhibit behaviors like temper tantrums and saying 'no' as they are asserting their independence and autonomy. This behavior is a normal part of their developmental stage where they are starting to explore and assert their own preferences and desires. Choice B, developing a sense of trust, is more relevant to infants during the trust vs. mistrust stage. Choice C, establishing a new identity, is typically associated with adolescence and identity formation. Choice D, attempting to master a skill, is more indicative of a child trying to learn and develop new abilities rather than the behavior described in the scenario.

5. A client is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

• A. “This test will indicate if you are at risk for developing blood clots.”
• B. “This test will determine if your heart is performing properly.”
• C. “This test will provide information about the function of your liver.”
• D. “This test is used to check how your kidneys are working.”

Correct answer: C

Rationale: The correct answer is C: “This test will provide information about the function of your liver.” Alanine aminotransferase (ALT) is an enzyme mainly found in the liver. An elevated ALT level may indicate liver damage or disease. Choices A, B, and D are incorrect because ALT is specifically related to liver function and not indicative of blood clot risk, heart performance, or kidney function.

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