Nursing Elites

1. A nurse is providing discharge teaching to a client who has hypertension about monitoring blood pressure at home. Which of the following instructions should the nurse include?

• A. Use a cuff that is too loose for the arm.
• B. Place the cuff over clothing.
• C. Sit quietly for 5 minutes before measuring your blood pressure.
• D. Use the same arm for each reading.

Correct answer: C

Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before measuring their blood pressure. This allows the body to relax and stabilize, leading to a more accurate reading. Choice A is incorrect because using a cuff that is too loose can result in inaccurate readings. Choice B is incorrect as the cuff should be placed directly on the bare skin. Choice D is incorrect as using the same arm for each reading is important for consistency in monitoring, but sitting quietly before measuring is crucial for accuracy.

2. A nurse is caring for a client who has right-sided heart failure. Which of the following findings should the nurse expect?

• A. Peripheral edema.
• B. JVD.
• C. Crackles in the lungs.
• D. Hypotension.

Correct answer: B

Rationale: The correct answer is B: JVD. Jugular venous distention (JVD) is a common finding in right-sided heart failure due to fluid overload. This occurs because the right side of the heart is unable to effectively pump blood, leading to congestion and increased venous pressure, which is manifested as JVD. Choices A, C, and D are incorrect. Peripheral edema (choice A) is more commonly associated with left-sided heart failure. Crackles in the lungs (choice C) are indicative of pulmonary edema, often seen in left-sided heart failure. Hypotension (choice D) is not typically seen in right-sided heart failure, as it is more commonly associated with conditions like shock or severe dehydration.

3. A client with a new colostomy requires care planning by a nurse. Which of the following interventions should the nurse include in the plan of care?

• A. Change the ostomy pouch every 4 to 7 days.
• B. Empty the ostomy pouch when it is half full.
• C. Apply a skin barrier around the stoma.
• D. Cleanse the peristomal skin with alcohol.

Correct answer: A

Rationale: The correct answer is to change the ostomy pouch every 4 to 7 days. This practice helps prevent skin irritation and leakage by maintaining a clean and secure seal around the stoma. Option B is incorrect because it is more important to change the pouch regularly rather than emptying it when half full. Option C is incorrect as applying a skin barrier is typically done during the initial application of the pouch, not during regular changes. Option D is incorrect because alcohol can be too harsh for the peristomal skin and can cause irritation.

4. A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the surgical dressing.
• B. Heart rate of 88/min.
• C. Blood pressure of 118/76 mm Hg.
• D. Temperature of 38.8°C (101.8°F).

Correct answer: D

Rationale: A temperature of 38.8°C (101.8°F) is above the normal range and may indicate infection, which should be reported. Elevated temperature postoperatively can be a sign of infection, especially in the early postoperative period. Serosanguineous drainage on the surgical dressing is expected in the early postoperative period. A heart rate of 88/min and a blood pressure of 118/76 mm Hg are within normal ranges and do not necessarily indicate a complication postoperatively.

5. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the unit due to a staffing shortage. Which of the following clients should the nurse delegate to the LPN?

• A. A client who has 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.
• D. A client who fractured his femur yesterday and is experiencing shortness of breath.

Correct answer: C

Rationale: The correct answer is C because a client who is postoperative following a bowel resection with an NG tube can be delegated to an LPN as this involves routine postoperative care. Option A involves administering packed RBCs which requires assessment and monitoring for potential adverse reactions, not suitable for delegation to an LPN. Option B requires neurological assessment and close monitoring due to the concussion, which is beyond the scope of an LPN. Option D involves a client with a recent fracture and shortness of breath, which requires urgent assessment and intervention beyond the LPN's scope of practice.

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