Nursing Elites

1. A nurse is preparing to perform postmortem care for a client. Which of the following actions should the nurse take?

• A. Place the client's dentures in a labeled container
• B. Remove the client's IV lines
• C. Place the client's body in a semi-fowler's position
• D. Lower the client's head of the bed

Correct answer: B

Rationale: The correct action for the nurse to take when preparing to perform postmortem care is to remove the client's IV lines. This step is essential to help maintain the dignity and appearance of the body. Placing the client's dentures in a labeled container (Choice A) is not a priority during postmortem care as the focus is on the body's preparation. While positioning the body in a semi-fowler's position (Choice C) or lowering the client's head of the bed (Choice D) are common practices for living clients to prevent aspiration, they are not necessary after death. Therefore, the immediate action of removing IV lines is most appropriate in this situation.

2. A nurse is planning assignments for a licensed practical nurse (LPN) during a staffing shortage. Which client should be delegated to the LPN?

• A. A client with an Hgb of 6.3 g/dl and a prescription for packed RBCs.
• B. A client who sustained a concussion and has unequal pupils.
• C. A client who is postoperative following a bowel resection with an NG tube set to continuous suction.
• D. A client who fractured his femur yesterday and is experiencing shortness of breath.

Correct answer: C

Rationale: The correct answer is C because the client postoperative following a bowel resection with an NG tube set to continuous suction requires routine postoperative care, which an LPN can manage. Choice A involves administering blood products, which typically requires assessment and monitoring by a registered nurse. Choice B indicates a potentially serious neurological condition that requires assessment by a higher-level provider. Choice D suggests a client experiencing respiratory distress, which requires immediate assessment and intervention by a registered nurse or physician.

3. A nurse is caring for a client who has a prescription for clozapine. Which of the following laboratory values should the nurse monitor?

• A. Monitor blood glucose levels
• B. Monitor WBC count
• C. Monitor platelet count
• D. Monitor hemoglobin levels

Correct answer: B

Rationale: The correct answer is to monitor the WBC count. Clozapine can cause agranulocytosis, a severe decrease in WBC count, which can increase the risk of infection. Monitoring the WBC count is essential to detect this potentially life-threatening condition early. Monitoring blood glucose levels (Choice A) is not directly related to clozapine use. Platelet count (Choice C) and hemoglobin levels (Choice D) are not typically affected by clozapine and are not the priority for monitoring in this case.

4. A nurse is assessing a client who has increased intracranial pressure (ICP). Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Increased level of consciousness.
• C. Tachycardia.
• D. Hyperactive bowel sounds.

Correct answer: C

Rationale: The correct answer is C: Tachycardia. In a client with increased intracranial pressure (ICP), tachycardia is a common finding. This is due to the body's compensatory mechanisms in response to the increased pressure. Bradycardia (choice A) is not typically associated with increased ICP and may indicate a different issue. Increased level of consciousness (choice B) is unlikely with increased ICP, as it often leads to altered mental status. Hyperactive bowel sounds (choice D) are not directly related to increased ICP and are more indicative of gastrointestinal issues.

5. How should signs of infection in a post-surgical patient be assessed?

• A. Check the surgical site
• B. Check the patient's vital signs
• C. Monitor for fever
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: Assessing the surgical site is crucial in identifying early signs of infection post-surgery. Changes such as redness, swelling, warmth, or drainage may indicate an infection developing. While monitoring vital signs and fever are important in infection assessment, they are general indicators and may not show localized signs at the surgical site. Checking for abnormal breath sounds is more relevant when assessing respiratory issues rather than infection at the surgical site.

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