Nursing Elites

1. A client has restraints on each extremity. Which of the following assessments should the nurse perform first?

• A. Peripheral pulses
• B. Comfort level
• C. Elimination needs
• D. Skin integrity

Correct answer: A

Rationale: When a client is restrained, the nurse should prioritize assessing peripheral pulses first. This assessment is crucial to monitor circulation and ensure the restraints are not impeding blood flow. Comfort level, elimination needs, and skin integrity are also important assessments; however, assessing peripheral pulses takes precedence to prevent complications such as impaired circulation and tissue damage. By assessing peripheral pulses initially, the nurse can promptly identify and address any circulation issues, which are critical in preventing serious complications.

2. A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the LPN/LVN include in this client's teaching plan?

• A. You will be able to bend at the waist to reach items on the floor in 8 weeks.
• B. Place a pillow between your knees while lying in bed to prevent hip dislocation.
• C. It is safe to use a walker to get out of bed, but you need assistance when walking.
• D. Take pain medication 30 minutes after your physical therapy sessions.

Correct answer: B

Rationale: The correct instruction to include in the teaching plan for a client who had a hemiarthroplasty of the left hip is to 'Place a pillow between your knees while lying in bed to prevent hip dislocation.' This technique helps maintain proper hip alignment and prevents dislocation during the postoperative recovery period. Choice A is incorrect because bending at the waist to reach items on the floor can strain the hip joint and is not recommended following hip surgery. Choice C is incorrect because using a walker alone without assistance can increase the risk of falls and injury, especially in the immediate postoperative period. Choice D is incorrect because pain medication should be taken as prescribed by the healthcare provider, not specifically timed after physical therapy sessions.

3. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

• A. The client's comfort level is increased when the nurse maintains eye contact while typing notes into the record
• B. The interview process is hindered by electronic documentation and may disrupt the flow of conversation
• C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
• D. Completing the electronic record during an interview is optional and not a legal obligation of the examining nurse

Correct answer: C

Rationale: The most accurate statement is that the nurse has a limited ability to observe nonverbal communication while entering the assessment electronically. This is because the nurse's focus is on typing or inputting data, which may lead to missing important nonverbal cues from the client. Choices A and B are incorrect as they do not address the limitation of observing nonverbal cues. Choice A is incorrect because breaking eye contact to type notes may hinder the client's comfort level. Choice B is incorrect because it states that electronic documentation enhances the interview process, which may not always be the case. Choice D is incorrect as completing the electronic record during an interview is typically a standard practice but not a legal obligation.

4. A client has a sodium level of 125. What findings should the nurse expect?

• A. Abdominal cramping
• B. Elevated blood pressure
• C. Decreased heart rate
• D. Increased thirst

Correct answer: A

Rationale: Low sodium levels (hyponatremia) often present with various symptoms, including abdominal cramping. Abdominal cramping is a common manifestation of hyponatremia due to the altered electrolyte balance. Option B ('Elevated blood pressure') is incorrect because low sodium levels typically lead to decreased blood pressure, not elevated. Option C ('Decreased heart rate') is incorrect as low sodium levels are more likely to cause an irregular heart rate rather than a decreased heart rate. Option D ('Increased thirst') is incorrect because excessive thirst is more commonly associated with high sodium levels (hypernatremia) rather than low sodium levels.

5. When assessing bowel sounds, what action should a healthcare professional take?

• A. Listen to the bowel sounds before performing abdominal palpation
• B. Auscultate for 2 minutes to determine if bowel sounds are present
• C. Place the diaphragm of the stethoscope over each quadrant
• D. Ask the client to cough while auscultating

Correct answer: C

Rationale: When assessing bowel sounds, it is crucial to listen before performing any palpation as palpation can alter bowel sounds. The correct technique involves placing the diaphragm of the stethoscope over each quadrant of the abdomen to listen for bowel sounds. Auscultating for at least 5 minutes is recommended to accurately determine the presence or absence of bowel sounds. Asking the client to cough is not necessary for assessing bowel sounds and may not provide relevant information. Therefore, option C is the correct choice as it follows the appropriate procedure for assessing bowel sounds.

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