Nursing Elites

1. A client is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action?

• A. Assess the client's perineum
• B. Administer pain medication
• C. Clean the area with a mild cleanser
• D. Apply a barrier cream to the affected area

Correct answer: A

Rationale: Assessing the client's perineum is the priority nursing action in this situation. By checking the perineum, the nurse can evaluate for skin damage, irritation, infection, or other issues that may be causing the client's pain. This assessment is crucial to determine the appropriate interventions needed to address the client's discomfort and prevent complications. Administering pain medication, cleaning the area with a mild cleanser, or applying a barrier cream are important interventions but should follow the initial assessment of the perineum to ensure comprehensive care and effective management of the client's condition. Prioritizing assessment allows for a targeted and individualized approach to care, enhancing the client's overall well-being.

2. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

• A. Remove the safety pin from the extinguisher.
• B. Aim the extinguisher at the base of the fire.
• C. Squeeze the handle to release the extinguishing agent.
• D. Sweep the extinguisher from side to side.

Correct answer: A

Rationale: The correct first step in using a fire extinguisher is to remove the safety pin. This action enables the extinguisher to be activated and used effectively. Choice B, aiming the extinguisher at the base of the fire, comes after removing the safety pin. Choice C, squeezing the handle to release the extinguishing agent, and choice D, sweeping the extinguisher from side to side, are subsequent steps in using a fire extinguisher and should follow removing the safety pin.

3. A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dL. What is the priority nursing action for the LPN/LVN?

• A. Administer insulin as prescribed.
• B. Administer oral hypoglycemic agents.
• C. Monitor blood glucose levels frequently.
• D. Provide a high-calorie diet.

Correct answer: A

Rationale: The correct answer is to administer insulin as prescribed. When a client with diabetes mellitus presents with a critically high blood glucose level like 600 mg/dL, the priority action is to lower the blood glucose level promptly to prevent complications. Insulin is the appropriate medication to rapidly reduce high blood glucose levels. Administering oral hypoglycemic agents may not act quickly enough in this critical situation. While monitoring blood glucose levels frequently is important, immediate intervention to lower the high blood glucose level takes precedence. Providing a high-calorie diet is contraindicated in this scenario as it would further elevate the blood glucose level.

4. The nurse is caring for a client with a urinary tract infection (UTI). Which finding should the LPN/LVN report to the healthcare provider immediately?

• A. Cloudy urine
• B. Burning sensation during urination
• C. Foul-smelling urine
• D. Blood in the urine

Correct answer: D

Rationale: The presence of blood in the urine in a client with a urinary tract infection (UTI) may indicate a more severe infection, such as pyelonephritis, or complications like kidney stones or bladder cancer. Therefore, this finding should be reported immediately for further evaluation and management. Cloudy urine, burning sensation during urination, and foul-smelling urine are common symptoms of UTI and may not necessarily signify an urgent need for immediate reporting compared to the presence of blood in the urine.

5. What are the correct steps used for abdominal assessment?

• A. Inspection, auscultation, percussion, palpation
• B. Palpation, inspection, auscultation, percussion
• C. Percussion, palpation, inspection, auscultation
• D. Auscultation, palpation, percussion, inspection

Correct answer: A

Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection allows the nurse to visually assess the abdomen for any abnormalities or distension. Auscultation follows to listen for bowel sounds and vascular sounds. Percussion helps to assess the density of underlying structures and detect any abnormal masses. Palpation is performed last to assess tenderness, organ size, and detect any masses. Choices B, C, and D have the steps in the incorrect order, making them the wrong choices.

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