Nursing Elites

1. A client is about to undergo emergency abdominal surgery for appendicitis. A healthcare professional is demonstrating postoperative deep breathing and coughing exercises to the client. The healthcare professional realizes the client may be unprepared to learn if the client:

• A. Is not feeling well
• B. Reports severe pain
• C. Has low blood pressure
• D. Is anxious

Correct answer: B

Rationale: Severe pain can be a significant distraction and impediment to the learning process. When a client is experiencing severe pain, their focus and attention are primarily directed towards managing the pain, making it difficult for them to absorb and retain new information effectively. Options A, C, and D, although important considerations in a healthcare setting, do not directly impact the client’s ability to learn in the same way that severe pain does. Not feeling well, low blood pressure, and anxiety are all factors that can be addressed or managed to facilitate learning, unlike severe pain which can significantly hinder the learning process.

2. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the LPN/LVN to take?

• A. Administer nitroglycerin sublingually.
• B. Obtain a 12-lead ECG.
• C. Measure the client's vital signs.
• D. Administer oxygen via nasal cannula.

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin sublingually. Administering nitroglycerin sublingually is the priority action for a client with chest pain and a history of coronary artery disease. Nitroglycerin helps dilate the coronary arteries, improving blood flow to the heart muscle and providing rapid relief of chest pain. Obtaining a 12-lead ECG, measuring vital signs, and administering oxygen are important actions but should follow the administration of nitroglycerin in the management of chest pain in a client with coronary artery disease.

3. A client is receiving morphine via PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?

• A. I'll wait to use the device until it's absolutely necessary.
• B. I'll be careful about pushing the button too much to avoid an overdose.
• C. I should tell the nurse if the pain doesn't stop while I am using this device.
• D. I will ask my adult child to push the dose button when I am sleeping.

Correct answer: C

Rationale: Choice C is the correct answer because it demonstrates that the client understands the importance of communicating with the nurse if the pain persists while using the PCA device. This is crucial as it ensures proper pain management and monitoring. Choices A and B are incorrect because delaying the use of the device until necessary or being cautious about pushing the button too much do not necessarily reflect understanding of using the PCA device effectively. Choice D is incorrect as having someone else, like an adult child, push the dose button goes against the principle of the client self-administering the medication through the PCA device.

4. An adult client is found to be unresponsive during morning rounds. After checking for responsiveness and calling for help, what should the nurse do next?

• A. Check the carotid pulse
• B. Deliver 5 abdominal thrusts
• C. Give 2 rescue breaths
• D. Open the client's airway

Correct answer: D

Rationale: After confirming unresponsiveness and calling for help, the next step in basic life support is to open the client's airway. This ensures that the airway is clear and allows for effective ventilation. Checking the carotid pulse is not necessary at this stage as airway management takes precedence. Delivering abdominal thrusts is not indicated for an unresponsive client as it is for conscious choking individuals. Giving rescue breaths should only be done after ensuring the airway is open to allow for effective ventilation.

5. Which statement by the mother indicates that the mother understands safety precautions with her four-month-old infant and her 4-year-old child?

• A. I secure the infant car seat in the back seat facing backwards.
• B. I place my infant in the middle of the living room floor on a blanket to play with my 4-year-old while I make supper in the kitchen.
• C. My sleeping baby looks adorable in the crib with the little buttocks up in the air while the four-year-old naps on the sofa.
• D. I have the 4-year-old hold and help feed the four-month-old a bottle in the kitchen while I make supper.

Correct answer: D

Rationale: Choice D is the correct answer because having the 4-year-old help feed the four-month-old a bottle in the kitchen while the mother makes supper shows supervision of the infant by the older child in a safe environment. This choice indicates that the mother understands safety precautions by involving the older child in a caregiving task under her supervision. Choices A, B, and C are incorrect because they involve unsafe practices such as placing the infant on the floor unsupervised, positioning the infant car seat in the front seat, and not providing direct supervision of the children during naptimes.

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