Nursing Elites

1. A client is 1-day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client’s medication administration record, which of the following medications should be administered?

• A. Meperidine 75 mg IM
• B. Fentanyl 50 mcg/hr transdermal patch
• C. Morphine 2 mg IV
• D. Oxycodone 10 mg PO

Correct answer: C

Rationale: Morphine IV is the most appropriate choice for severe postoperative pain due to its rapid onset and effectiveness. Meperidine is not preferred due to its potential side effects, and fentanyl patches are typically used for chronic pain, not acute postoperative pain. Oxycodone taken orally is not ideal for providing immediate relief in this situation.

2. A client with a history of chronic renal failure is admitted with generalized edema. Which laboratory value should the LPN/LVN monitor to assess the client's fluid balance?

• A. Serum potassium
• B. Serum calcium
• C. Serum albumin
• D. Serum sodium

Correct answer: C

Rationale: The correct answer is C, Serum albumin. In clients with chronic renal failure and generalized edema, monitoring serum albumin levels is crucial as it is a key indicator of fluid balance. Low serum albumin levels can contribute to edema formation due to decreased oncotic pressure, indicating fluid imbalance. Serum potassium (Choice A) is more related to kidney function and electrolyte balance in renal failure patients. Serum calcium (Choice B) is important for bone health but is not directly related to fluid balance. Serum sodium (Choice D) is more indicative of hydration status and electrolyte balance but may not directly reflect fluid balance in the context of chronic renal failure and edema.

3. While measuring a client’s vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?

• A. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart
• B. Measure the blood pressure
• C. Perform an ECG
• D. Recheck the heart rate after 5 minutes

Correct answer: A

Rationale: The appropriate nursing action when an irregularity in the heart rate is observed is to count the apical pulse rate for a full minute and describe the rhythm in the chart. This approach helps in obtaining an accurate assessment of the irregularities present. Measuring the blood pressure (Choice B) is important but not the immediate priority when an irregular heart rate is noted. Performing an ECG (Choice C) may be necessary but is a more advanced intervention that should follow the initial assessment. Rechecking the heart rate after 5 minutes (Choice D) may delay potential interventions for addressing the irregularity, making it less appropriate than the immediate assessment and documentation of the pulse rhythm.

4. When performing nasotracheal suctioning on a client with a respiratory infection, what technique should be used?

• A. Apply intermittent suction when withdrawing the catheter.
• B. Apply continuous suction during insertion of the catheter.
• C. Apply suction only during insertion of the catheter.
• D. Insert the catheter while the client is exhaling.

Correct answer: A

Rationale: The correct technique for nasotracheal suctioning is to apply intermittent suction when withdrawing the catheter. This method helps prevent damage to the mucosa and is the recommended approach. Continuous suction during insertion (choice B) can cause trauma to the airway lining. Applying suction only during insertion (choice C) is not sufficient for effective removal of secretions. Inserting the catheter while the client is exhaling (choice D) does not follow the standard procedure for nasotracheal suctioning.

5. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following?

• A. Hypotension
• B. Bradycardia
• C. Clammy skin
• D. Bradypnea

Correct answer: A

Rationale: The correct answer is A: Hypotension. Heat stroke is characterized by elevated body temperature, which can lead to hypotension (low blood pressure) due to dehydration and vasodilation. Bradycardia (slow heart rate) and clammy skin are not typical findings in heat stroke. Bradypnea (slow breathing) is also not a common feature of heat stroke. Therefore, hypotension is the most likely cardiovascular manifestation seen in a client with heat stroke.

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