Nursing Elites

1. While providing care to a group of patients, which patient should the nurse prioritize seeing first?

• A. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
• B. A bedridden patient with a reddened area on the buttocks who needs to be turned
• C. A patient on bed rest with renal calculi who needs to go to the bathroom
• D. A patient post-knee surgery who needs range of motion exercises

Correct answer: A

Rationale: The nurse should prioritize seeing the patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea first. This patient is at higher risk for deep vein thrombosis due to prolonged bed rest, which can lead to a life-threatening embolus. Chest pain and dyspnea could also indicate a potential pulmonary embolism, which requires immediate assessment and intervention. The other patients, while requiring care, do not present with symptoms that suggest an immediate life-threatening situation, making them lower priority at this time. Therefore, option A is the correct choice as it addresses a potentially critical condition that requires immediate attention.

2. A healthcare professional is reviewing the medical record of a client who has hypocalcemia. The healthcare professional should identify which of the following findings as a risk factor for the development of this electrolyte imbalance?

• A. Crohn’s disease
• B. Postoperative status following appendectomy
• C. History of bone cancer
• D. Hyperthyroidism

Correct answer: A

Rationale: Crohn’s disease is known to impair calcium absorption, which can lead to hypocalcemia. This condition affects the intestines and can disrupt the normal absorption of nutrients, including calcium. Postoperative status following appendectomy, history of bone cancer, and hyperthyroidism are typically not directly associated with a higher risk of developing hypocalcemia compared to Crohn’s disease.

3. During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the LPN/LVN implement?

• A. Provide additional coffee on the client's breakfast tray.
• B. Exchange the client's grape juice for cranberry juice.
• C. Bring the client additional fruit at mid-morning.
• D. Encourage additional oral intake of juices and water.

Correct answer: D

Rationale: Encouraging additional oral intake of juices and water is the appropriate intervention in this scenario. Dark amber urine can indicate concentrated urine due to dehydration or other factors. By encouraging more fluids, the LPN/LVN can help dilute the urine, reducing the concentration of pigments causing the dark color. Providing additional coffee (Choice A) would not necessarily increase hydration and could potentially have a diuretic effect. Exchanging grape juice for cranberry juice (Choice B) does not address the core issue of hydration. Bringing additional fruit (Choice C) may provide some fluid, but encouraging specific fluids like juices and water would be more effective in diluting the urine.

4. A healthcare professional is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the healthcare professional identify as an indication that the treatment was successful?

• A. Decrease in heart rate
• B. Fluid volume deficit causes tachycardia
• C. Decrease in blood pressure
• D. Increase in respiratory rate

Correct answer: A

Rationale: A decrease in heart rate can indicate that the fluid volume deficit is improving. In cases of fluid volume deficit, the body compensates by increasing the heart rate to maintain adequate perfusion. Therefore, a decrease in heart rate after fluid resuscitation suggests that the body's perfusion status is improving. Choices B, C, and D are incorrect because fluid volume deficit typically causes tachycardia, not a decrease in heart rate, and would not result in a decrease in blood pressure or an increase in respiratory rate as primary signs of improvement.

5. A healthcare professional is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

• A. Ventrogluteal
• B. Dorsogluteal
• C. Deltoid
• D. Vastus lateralis

Correct answer: A

Rationale: The ventrogluteal site is considered the safest for intramuscular injections in young adult clients due to its location away from major nerves and blood vessels. The ventrogluteal site is preferred over the dorsogluteal site, as the latter is associated with a higher risk of injury to the sciatic nerve. The deltoid site is commonly used for vaccines but may not be suitable for all intramuscular injections due to smaller muscle mass. The vastus lateralis site is often used in infants and young children, but in young adults, the ventrogluteal site is preferred for safety and efficacy.

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