Nursing Elites

1. A nurse is preparing change of shift report after the night shift using one SBAR communication tool. Which of the following data should the nurse include when reporting background information?

• A. “Blood pressure 160/92 mm Hg”
• B. “Start the first dose of penicillin at 1200”
• C. “Pain rating of 5 on a scale from 0 to 10”
• D. “Code status: do-not-resuscitate”

Correct answer: B

Rationale: The correct answer is B. When providing background information in a shift report using the SBAR communication tool, the nurse should include details related to medication administration and orders. This helps ensure continuity of care and accurate handover of responsibilities. Choices A, C, and D do not typically fall under background information for shift reports. A blood pressure reading, pain rating, and code status are more relevant to the patient's current condition and status, rather than background information about medications or orders.

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

• A. Administer oxygen via a nasal cannula.
• B. Measure the client's vital signs.
• C. Obtain a 12-lead ECG.
• D. Encourage the client to use pursed-lip breathing.

Correct answer: A

Rationale: Administering oxygen via a nasal cannula is the priority action for a client experiencing chest pain due to coronary artery disease. Oxygen therapy helps improve oxygenation, reduce myocardial workload, and relieve chest pain by increasing oxygen delivery to the heart muscle. While measuring vital signs, obtaining a 12-lead ECG, and encouraging pursed-lip breathing are important interventions, administering oxygen takes precedence in this situation to address the potential hypoxemia associated with chest pain in a client with a history of coronary artery disease.

3. During the stages of dying, a client reaches the point of acceptance. What response should the LPN/LVN expect the client to exhibit?

• A. Apathy
• B. Euphoria
• C. Detachment
• D. Emotionalism

Correct answer: C

Rationale: During the stages of dying, when a client reaches the point of acceptance, the expected response is 'Detachment.' This is characterized by the individual withdrawing emotionally and psychologically from their surroundings as they come to terms with their impending death. Apathy (Choice A) refers to a lack of interest, enthusiasm, or concern, which is not typically associated with the acceptance stage. Euphoria (Choice B) is an intense feeling of happiness or excitement, which is less likely during the acceptance stage of dying. Emotionalism (Choice D) involves exaggerated or uncontrollable emotional reactions, which are not commonly seen during the acceptance phase.

4. The healthcare professional prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The healthcare professional should regulate the IV to administer approximately how many drops per minute?

• A. 80
• B. 8
• C. 21
• D. 25

Correct answer: C

Rationale: To calculate the drops per minute for the IV infusion, first determine the total drops to be infused over 8 hours. 1,000 ml to be infused over 8 hours means 125 ml per hour (1000 ml / 8 hours = 125 ml/hr). Since the infusion set delivers 10 drops per ml, 125 ml/hr x 10 drops/ml = 1250 drops/hr. To find drops per minute, divide the drops per hour by 60 (minutes in an hour): 1250 drops/hr / 60 minutes = 20.83 drops/minute, which rounds up to 21 drops per minute (Option C). This rate ensures the correct infusion rate over 8 hours. Choices A, B, and D are incorrect calculations and do not provide the appropriate infusion rate needed to administer the IV over the specified time period.

5. A young mother of three children complains of increased anxiety during her annual physical exam. What information should the LPN/LVN obtain first?

• A. Sexual activity patterns.
• B. Nutritional history.
• C. Leisure activities.
• D. Financial stressors.

Correct answer: B

Rationale: The LPN/LVN should first obtain the nutritional history in this scenario. Nutrition plays a crucial role in mental health, and deficiencies or imbalances in diet can contribute to anxiety symptoms. Understanding the mother's nutritional intake can help identify any factors exacerbating her anxiety. Sexual activity patterns are not directly relevant to her anxiety symptoms unless specifically indicated. Leisure activities and financial stressors may be important but are secondary to addressing the potential impact of nutrition on anxiety.

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