Nursing Elites

1. A client is being taught how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client’s motivation to learn?

• A. The client’s belief that his needs will be met through education
• B. The nurse’s empathy regarding the client's self-injection
• C. The client seeking family approval by agreeing to a teaching plan
• D. The nurse explaining the need for education to the client

Correct answer: A

Rationale: The client's belief that his needs will be met through education is the most likely factor to increase motivation to learn. When individuals perceive that their educational efforts will directly benefit them, they are more motivated to engage in the learning process. Empathy from the nurse, seeking family approval, or the nurse explaining the need for education may not be as directly tied to the client's personal benefit and may not necessarily increase motivation to learn.

2. An assistive personnel tells the nurse, 'I am unable to find a large blood pressure cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?' The nurse replies that taking the blood pressure of a morbidly obese client with a regular blood pressure cuff will result in a reading that is:

• A. Low
• B. High
• C. Inaccurate
• D. Unaffected

Correct answer: B

Rationale: Using a regular blood pressure cuff on a morbidly obese client will lead to a falsely high blood pressure reading. This occurs because the cuff is not appropriately sized for the client's arm circumference, resulting in increased pressure on the artery and an inaccurate high reading. Choice A is incorrect because the reading will be falsely high, not low. Choice C is incorrect as the reading will not be accurate with an incorrectly sized cuff. Choice D is incorrect because the reading will be affected by using the wrong cuff size.

3. A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest?

• A. Establish consistent boundaries for the toddler.
• B. Place the toddler in a room with the door closed.
• C. Inform the toddler how you feel when he misbehaves.
• D. Use a favorite snack to reward the toddler.

Correct answer: A

Rationale: The correct answer is to establish consistent boundaries for the toddler. This approach helps toddlers understand expectations and promotes consistent behavior. Placing the toddler alone or using food rewards may not effectively teach discipline and could be inappropriate. Informing the toddler about feelings when misbehaving may not be developmentally appropriate for a toddler to understand the consequences of their actions.

4. A client with a history of peptic ulcer disease is admitted with abdominal pain. Which finding should the LPN/LVN report to the healthcare provider immediately?

• A. Positive bowel sounds
• B. Rebound tenderness
• C. Increased appetite
• D. Elevated temperature

Correct answer: D

Rationale: Elevated temperature is the correct finding to report immediately in a client with a history of peptic ulcer disease and abdominal pain. This could indicate a perforation or worsening of the condition, requiring prompt medical attention. Positive bowel sounds (Choice A) are a normal finding and not a cause for concern. Rebound tenderness (Choice B) is concerning but does not require immediate attention compared to an elevated temperature. Increased appetite (Choice C) is not a red flag symptom for peptic ulcer disease and can be considered a positive sign, not requiring immediate attention.

5. A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the LPN/LVN to implement?

• A. Obtain the pre-transfusion hemoglobin level.
• B. Prime the tubing and set up the blood pump.
• C. Monitor vital signs every 15 minutes for the first hour.
• D. Ensure the accuracy of the blood type match.

Correct answer: D

Rationale: Ensuring the accuracy of the blood type match is crucial to prevent transfusion reactions. The LPN/LVN must prioritize this step to avoid adverse outcomes. Obtaining the pre-transfusion hemoglobin level (Option A) is important but not as critical as ensuring blood type compatibility. Priming the tubing and setting up the blood pump (Option B) and monitoring vital signs every 15 minutes (Option C) are essential steps in the transfusion process, but the primary concern should be preventing transfusion reactions by verifying blood type compatibility.

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