Nursing Elites

1. A client is scheduled for an appendectomy and has given informed consent. Which statement by the client should the nurse address first preoperatively?

• A. “I am afraid to walk if it hurts too much.”
• B. “I don’t understand why I need this surgery.”
• C. “I don’t want my family helping me after the surgery.”
• D. “I am afraid the scar will make me look disfigured.”

Correct answer: B

Rationale: The nurse should address the client's lack of understanding regarding the need for surgery first. Ensuring that the client comprehends the rationale for the procedure is essential for informed consent. Choices A, C, and D, while important, do not directly impact the client's understanding of the necessity of the surgery and can be addressed after clarifying the reason for the procedure.

2. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily?

• A. Spaghetti
• B. Watermelon
• C. Chicken
• D. Tomatoes

Correct answer: B

Rationale: The correct answer is 'Watermelon.' Watermelon is high in potassium, which is important to counteract the potassium loss caused by furosemide. Furosemide is a loop diuretic that can lead to potassium depletion, so consuming potassium-rich foods like watermelon can help maintain electrolyte balance. Choices A, C, and D do not specifically address the need for potassium in this scenario and are not as beneficial for addressing the potential electrolyte imbalance caused by furosemide.

3. A client had a mastectomy 6 months ago and expresses a decreased desire for sexual relations, stating “My body is so different now.” Which of the following responses should the nurse make?

• A. “Really, you look just fine to me. There’s no need to feel undesirable.”
• B. “I’m interested in finding out more about how your body feels to you.”
• C. “Consider an afternoon at a spa; a facial will make you feel more attractive.”
• D. “It’s still too soon to expect to feel normal. Give it a little more time.”

Correct answer: B

Rationale: In this situation, the appropriate response is to reflect on the client’s feelings and explore their experience. Choice A may unintentionally dismiss the client's concerns by not addressing their emotional needs. Choice C suggests a spa treatment as a solution without addressing the underlying emotional issues. Choice D implies that the client's feelings will resolve with time, which may not be helpful in addressing the client's current emotional state.

4. A client with a history of deep vein thrombosis (DVT) is admitted with swelling and pain in the left leg. What is the most appropriate action for the LPN/LVN to take?

• A. Apply warm compresses to the affected leg.
• B. Elevate the left leg above the level of the heart.
• C. Measure the circumference of the left leg.
• D. Administer pain medication as prescribed.

Correct answer: C

Rationale: Measuring the circumference of the left leg is the most appropriate action for an LPN/LVN when assessing a client with a history of DVT and presenting with swelling and pain in the left leg. This measurement helps to assess the extent of swelling objectively and monitor changes in the client's condition. Applying warm compresses (Choice A) may worsen the condition by potentially promoting clot development. Elevating the left leg above the level of the heart (Choice B) is generally recommended for DVT to improve venous return, but measuring the circumference is more appropriate in this scenario. Administering pain medication (Choice D) does not address the underlying issue and should not be the initial action taken.

5. A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the LPN give the client about this medication?

• A. Prolonged use does not typically cause dark concentrated urine.
• B. It is not necessary to take the medication on an empty stomach for optimal absorption.
• C. Avoid taking the medication with aluminum hydroxide to minimize GI upset.
• D. Drinking alcohol daily can cause drug-induced hepatitis.

Correct answer: D

Rationale: The correct answer is D. When taking isoniazid, alcohol consumption should be avoided as it can increase the risk of liver damage, potentially leading to drug-induced hepatitis. Choices A, B, and C are incorrect. Prolonged use of isoniazid does not typically cause dark concentrated urine; it is not necessary to take the medication on an empty stomach for optimal absorption; and it is not recommended to take isoniazid with aluminum hydroxide to minimize GI upset.

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