Nursing Elites

1. A healthcare professional is reviewing a client's fluid and electrolyte status. Which of the following findings should the healthcare professional report to the provider?

• A. BUN 15 mg/dL
• B. Creatinine 0.8 mg/dL
• C. Sodium 143 mEq/L
• D. Potassium 5.4 mEq/L

Correct answer: D

Rationale: The correct answer is D. A potassium level of 5.4 mEq/L is above the expected reference range, indicating hyperkalemia. Hyperkalemia can lead to serious complications such as dysrhythmias, making it important for the healthcare professional to report this finding to the provider for further evaluation and intervention. Choices A, B, and C fall within normal ranges and do not pose an immediate risk to the client's health, so they would not warrant immediate reporting to the provider. Elevated BUN or creatinine levels may indicate kidney dysfunction, while a sodium level of 143 mEq/L falls within the normal range for adults and does not typically require urgent intervention.

2. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse?

• A. Reassure the client that he will become accustomed to the stoma's appearance in time.
• B. Instruct the client that the stoma will become smaller when the initial swelling diminishes.
• C. Offer to contact a member of the local ostomy support group to help him with his concerns.
• D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

Correct answer: B

Rationale: The correct response is to instruct the client that the stoma will become smaller when the initial swelling diminishes. This explanation helps reassure the client about the temporary appearance of the stoma. Choice A is incorrect because simply reassuring the client that he will become accustomed to the stoma's appearance does not address the immediate concern about the stoma size. Choice C is incorrect because offering to contact a support group does not directly address the client's current distress about the stoma size. Choice D is incorrect because encouraging the client to handle stoma equipment does not directly address the client's concern about the stoma size and may not be appropriate at this time.

3. A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take?

• A. Establish goals that are measurable and realistic.
• B. Set goals that are a little beyond the capabilities of the patient.
• C. Use the nurse's own judgment and not be swayed by family desires.
• D. Explain that without taking alignment risks, there can be no progress.

Correct answer: A

Rationale: When developing an individualized plan of care for a patient, the nurse must set goals that are specific, measurable, achievable, realistic, and time-bound (SMART). Choice A is correct as it emphasizes the importance of establishing goals that are measurable and realistic, ensuring they are attainable within a specific timeframe. Setting goals that are beyond the capabilities of the patient (Choice B) can lead to frustration and lack of progress. Using only the nurse's judgment and disregarding family desires (Choice C) may not consider important aspects of the patient's social support and preferences. Explaining that progress requires taking alignment risks (Choice D) is not a standard approach in nursing care planning and may confuse the patient or hinder trust in the nurse's decision-making.

4. During a skin assessment, a healthcare professional is observing a group of clients. Which of the following lesions should the healthcare professional identify as vesicles?

• A. Acne
• B. Warts
• C. Psoriasis
• D. Herpes simplex

Correct answer: D

Rationale: Vesicles are small fluid-filled blisters. Herpes simplex is an example of a vesicular lesion, characterized by small, fluid-filled blisters. Acne presents as comedones, papules, pustules, or nodules, not vesicles. Warts are caused by the human papillomavirus and appear as rough, raised growths. Psoriasis is a chronic autoimmune condition that results in red, scaly patches on the skin, not vesicles.

5. A client is being taught how to use an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will try to seal my lips around the mouthpiece
• B. I will use the spirometer as needed throughout the day
• C. I will inhale slowly and deeply when using the spirometer
• D. I will seal my lips around the mouthpiece

Correct answer: D

Rationale: The correct answer is D. Sealing the lips around the mouthpiece is crucial for the proper use of an incentive spirometer as it helps ensure effective delivery of the inhaled medication. Choice A has been corrected to reflect the importance of sealing the lips. Choices B and C are incorrect because using the spirometer as needed throughout the day and inhaling slowly and deeply, although beneficial, do not directly address the essential technique of sealing the lips around the mouthpiece.

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