Nursing Elites

1. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?

• A. Discontinue the machine and measure the blood pressure manually every 15 minutes.
• B. Adjust the machine settings.
• C. Clean the machine to ensure accuracy.
• D. Increase the frequency of the readings.

Correct answer: B

Rationale: In this scenario, the nurse should adjust the machine settings. If the electronic blood pressure machine is providing varied intervals and inconsistent readings, it indicates a potential malfunction. Changing the settings may help correct the issue and ensure accurate measurements. Discontinuing the machine and measuring manually every 15 minutes (Choice A) may be time-consuming and impractical. Cleaning the machine (Choice C) is important for routine maintenance but may not address the current issue of varied intervals and inconsistent readings. Increasing the frequency of the readings (Choice D) does not address the problem of inaccurate measurements caused by the malfunctioning machine.

2. After abdominal surgery, a client has not urinated since the urinary catheter was removed 8 hours ago. What action should the LPN take first?

• A. Perform a bladder scan to assess for urinary retention.
• B. Encourage the client to drink fluids.
• C. Insert a straight catheter to drain the bladder.
• D. Administer a diuretic as prescribed.

Correct answer: A

Rationale: Performing a bladder scan is the initial step to assess for urinary retention in a postoperative client. This non-invasive technique helps determine the volume of urine in the bladder, guiding further interventions. Encouraging the client to drink fluids (Choice B) may be beneficial but is not the priority when assessing for urinary retention. Inserting a straight catheter (Choice C) should not be the initial action without first assessing for retention. Administering a diuretic (Choice D) should not be done without confirming the need through assessment.

3. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

• A. Activate the emergency fire alarm
• B. Extinguish the fire
• C. Evacuate the client
• D. Confine the fire

Correct answer: C

Rationale: The correct action for the nurse to take next, after confirming the fire, is to evacuate the client. In a fire situation, following the RACE mnemonic, the priority is to rescue or evacuate clients to ensure their safety. Activating the emergency fire alarm (Choice A) is important to alert others and the fire department, but evacuating the client takes precedence. Extinguishing the fire (Choice B) may put the nurse and client at risk and is best left to trained personnel. Confining the fire (Choice D) is not the nurse's responsibility; the focus should be on ensuring the client's safety by evacuating them.

4. A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse plan to implement when working with the client?

• A. Airborne
• B. Droplet
• C. Protective
• D. Contact

Correct answer: A

Rationale: Tuberculosis is an infectious disease that requires airborne precautions to prevent the transmission of infectious droplets. Airborne precautions involve wearing a mask, such as an N95 respirator, to protect against inhaling infectious particles. Droplet precautions are for diseases spread through respiratory droplets larger than those in airborne transmission, such as influenza. Protective precautions are not specific to respiratory infections and are more general measures to protect patients from harm. Contact precautions are used for diseases spread by direct or indirect contact, such as MRSA or C. diff infections, not for tuberculosis.

5. A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the LPN/LVN to implement?

• A. Obtain the pre-transfusion hemoglobin level.
• B. Prime the tubing and set up the blood pump.
• C. Monitor vital signs every 15 minutes for the first hour.
• D. Ensure the accuracy of the blood type match.

Correct answer: D

Rationale: Ensuring the accuracy of the blood type match is crucial to prevent transfusion reactions. The LPN/LVN must prioritize this step to avoid adverse outcomes. Obtaining the pre-transfusion hemoglobin level (Option A) is important but not as critical as ensuring blood type compatibility. Priming the tubing and setting up the blood pump (Option B) and monitoring vital signs every 15 minutes (Option C) are essential steps in the transfusion process, but the primary concern should be preventing transfusion reactions by verifying blood type compatibility.

Similar Questions