Nursing Elites

1. A client with a terminal illness is being educated by a healthcare provider about declining resuscitation in a living will. The client asks, “What would happen if I arrived at the ED and I had difficulty breathing?”

• A. We would give you oxygen through a tube in your nose.
• B. We would initiate full resuscitation efforts.
• C. We would consult the living will and provide comfort care.
• D. We would not provide any medical intervention.

Correct answer: C

Rationale: In the scenario described, the client has a living will that declines resuscitation. Therefore, if the client arrives at the emergency department with difficulty breathing, healthcare providers would consult the living will to understand the client's wishes. Providing comfort care, which may include oxygen therapy to alleviate symptoms, aligns with the client's preferences. Option A incorrectly suggests an intervention that goes against the client's wishes. Option B is incorrect because full resuscitation efforts are not in line with the client's choice to decline resuscitation. Option D is also incorrect as it does not consider the client's living will and the need to provide care according to the documented preferences of the client.

2. A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the LPN/LVN monitor this client?

• A. Curling ulcer
• B. Renal shutdown
• C. Metabolic acidosis
• D. Hemolysis of red blood cells

Correct answer: C

Rationale: Corrected Rationale: Metabolic acidosis is a serious side effect of mafenide therapy that should be closely monitored. Mafenide can lead to metabolic acidosis due to its inhibition of carbonic anhydrase, resulting in the accumulation of carbonic acid. Curling ulcer (Choice A) is a stress-related mucosal lesion that occurs in the duodenum, primarily due to severe burns, not directly related to mafenide therapy. Renal shutdown (Choice B) is not a common side effect of mafenide therapy. Hemolysis of red blood cells (Choice D) is not a recognized side effect of mafenide cream application.

3. The nurse is caring for a client with a newly placed colostomy. Which statement by the client indicates a need for additional teaching?

• A. I will need to change the colostomy bag every day.
• B. I should avoid foods that can cause gas, such as beans and carbonated drinks.
• C. I need to empty the colostomy bag when it is one-third to one-half full.
• D. I will need to take care of the skin around the stoma to prevent irritation.

Correct answer: A

Rationale: The correct answer is A. Changing the colostomy bag every day is not necessary; it should be changed as needed, usually every 3-7 days. This statement indicates a need for additional teaching as frequent changes can irritate the skin and are not typically required. Choices B, C, and D are all correct statements regarding colostomy care. Avoiding gas-producing foods, emptying the bag when it is one-third to one-half full, and taking care of the skin around the stoma are all essential aspects of colostomy care to prevent complications and maintain skin integrity.

4. The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. Which assessment finding would prompt the nurse to withhold the medication and contact the healthcare provider?

• A. Heart rate of 55 beats per minute
• B. Blood pressure of 140/90 mmHg
• C. Respiratory rate of 20 breaths per minute
• D. Blood glucose level of 150 mg/dL

Correct answer: A

Rationale: A heart rate below 60 beats per minute is a contraindication for administering digoxin, as it can lead to bradycardia. Bradycardia is a common adverse effect associated with digoxin toxicity. Blood pressure of 140/90 mmHg, respiratory rate of 20 breaths per minute, and blood glucose level of 150 mg/dL are within normal limits and would not warrant withholding the medication or contacting the healthcare provider in this context. Therefore, a heart rate of 55 beats per minute would prompt the nurse to withhold digoxin and notify the healthcare provider.

5. The nurse is caring for an adult who has fluid volume excess. When weighing the client, the nurse should:

• A. Weigh the client upon rising
• B. Weigh the client at different times of the day
• C. Weigh the client after meals
• D. Weigh the client weekly

Correct answer: A

Rationale: Weighing the client upon rising is the correct approach when caring for a client with fluid volume excess. Weighing the client in the morning upon rising provides a consistent and accurate measure of weight, as it helps to eliminate the influence of daily fluctuations that can occur throughout the day. Weighing at different times of the day (choice B) may lead to inconsistent measurements due to variations in food intake, hydration status, and other factors. Weighing the client after meals (choice C) can also lead to inaccurate readings as food and fluid intake can affect weight. Weighing the client weekly (choice D) is not frequent enough to monitor changes in weight accurately for a client with fluid volume excess.

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