Nursing Elites

1. A patient uses an in-the-canal hearing aid. Which assessment is a priority?

• A. Eyeglass usage
• B. Cerumen buildup
• C. Type of physical exercise
• D. Excessive moisture problems

Correct answer: B

Rationale: When a patient uses an in-the-canal hearing aid, cerumen buildup is a critical issue that needs to be regularly assessed. Cerumen can easily block the sound passage and affect the functionality of the hearing aid. Assessing and managing cerumen buildup is a priority to ensure the proper functioning of the hearing aid. Eyeglass usage, type of physical exercise, and excessive moisture problems are not directly related to the specific issue of cerumen buildup in in-the-canal hearing aids, making them lower priority assessments in this context.

2. When providing mouth care for an unconscious client, what action should the nurse take?

• A. Turn the client’s head to the side.
• B. Place two fingers in the client’s mouth to open it.
• C. Brush the client’s teeth once per day.
• D. Inject mouth rinse into the center of the client’s mouth.

Correct answer: A

Rationale: When providing mouth care for an unconscious client, the nurse should turn the client’s head to the side. This action helps prevent aspiration by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Placing fingers into the client’s mouth can be dangerous and may cause injury. Brushing the client’s teeth only once a day may not be sufficient for proper oral hygiene care. Injecting mouth rinse into the center of the mouth is not recommended and can potentially lead to aspiration. Therefore, the correct action for the nurse to take is to turn the client’s head to the side.

3. A healthcare professional is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care?

• A. HR 105/min
• B. BMI 25 kg/m²
• C. BP 148/92
• D. Glucose 45 mg/dL

Correct answer: D

Rationale: The correct answer is D, 'Glucose 45 mg/dL.' Glucose level of 45 mg/dL indicates hypoglycemia, which is a critical condition requiring immediate attention to prevent complications like seizures, loss of consciousness, and even coma. Hypoglycemia can lead to serious adverse outcomes if not promptly addressed. Choices A, B, and C do not represent immediate life-threatening conditions and can be managed as part of routine care, unlike hypoglycemia which demands urgent intervention.

4. A client is admitted with a diagnosis of septicemia. Which assessment finding should the LPN/LVN report to the healthcare provider immediately?

• A. Increased urine output
• B. Decreased blood pressure
• C. Increased heart rate
• D. Increased respiratory rate

Correct answer: B

Rationale: In a client with septicemia, decreased blood pressure is a critical finding that suggests potential septic shock, a life-threatening condition. Septic shock requires immediate medical intervention to prevent further deterioration and organ dysfunction. Increased urine output (Choice A) may indicate adequate fluid resuscitation, which is a positive response. Increased heart rate (Choice C) and increased respiratory rate (Choice D) are common physiological responses to sepsis and do not necessarily indicate immediate life-threatening complications like decreased blood pressure does in septic shock.

5. By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

• A. Reassess the client to determine the reasons for inadequate pain relief.
• B. Wait to see whether the pain lessens during the next 24 hours.
• C. Change the plan of care to provide different pain relief interventions.
• D. Teach the client about the plan of care for managing pain.

Correct answer: A

Rationale: Reassessing the client is crucial to identify the reasons for inadequate pain relief. This action allows the nurse to gather more information, evaluate the current pain management interventions, and make necessary adjustments to the care plan. Waiting for the pain to lessen without taking action delays appropriate pain management. Changing the plan of care without reassessment may lead to ineffective interventions. Teaching the client about the plan of care should be based on a reassessment of the current pain relief status to ensure tailored and effective pain management strategies.

Similar Questions