Nursing Elites

1. An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question?

• A. Assisting a client who is 24 hr postop to use an incentive spirometer
• B. Collecting a clean catch urine specimen from a client who was admitted on the previous shift
• C. Providing nasopharyngeal suctioning for a client who has pneumonia
• D. Replacing the cartridge and tubing on a PCA pump

Correct answer: D

Rationale: The LPN should question the assignment of replacing the PCA pump cartridge and tubing as it is outside the LPN's scope of practice. LPNs are not trained to handle tasks related to PCA pumps, which involve medication administration and monitoring that are typically within the RN's responsibilities. Assisting a postop client with an incentive spirometer (Choice A), collecting a clean catch urine specimen (Choice B), and providing nasopharyngeal suctioning for a client with pneumonia (Choice C) are all tasks that fall within the LPN's scope of practice and do not require questioning by the LPN.

2. A nurse is planning care for a client who is at 28 weeks of gestation and has preeclampsia. Which of the following interventions should the nurse include in the plan?

• A. Restrict the client's fluid intake.
• B. Monitor the client's deep-tendon reflexes.
• C. Place the client in the lithotomy position.
• D. Encourage the client to ambulate frequently.

Correct answer: B

Rationale: The correct answer is to monitor the client's deep-tendon reflexes. Monitoring deep-tendon reflexes is crucial in clients with preeclampsia as hyperreflexia can indicate severe complications. Restricting the client's fluid intake is not recommended as hydration is essential. Placing the client in the lithotomy position can worsen preeclampsia by reducing blood flow to the heart, so it should be avoided. Encouraging the client to ambulate frequently may not be suitable for a client with preeclampsia due to the risk of falls and increased stress on the body.

3. What is a primary symptom of left-sided heart failure?

• A. Shortness of breath
• B. Edema
• C. Rapid heartbeat
• D. Confusion

Correct answer: A

Rationale: Shortness of breath is a primary symptom of left-sided heart failure. In this condition, the heart's inability to pump effectively leads to fluid backing up into the lungs, causing difficulty breathing. Edema (swelling), rapid heartbeat, and confusion are more commonly associated with other conditions or right-sided heart failure. Edema is often seen in right-sided heart failure due to fluid accumulation in the body, rapid heartbeat can be a general sign of heart issues, and confusion is more related to decreased brain perfusion in severe heart failure cases.

4. What are the signs of hypoglycemia, and how should they be managed?

• A. Sweating, trembling; administer glucose
• B. Headache, confusion; administer insulin
• C. Dizziness, fatigue; administer glucose
• D. Increased heart rate; provide a high-sugar snack

Correct answer: A

Rationale: The correct signs of hypoglycemia are sweating and trembling. These should be managed by administering glucose to raise blood sugar levels. Headache, confusion, dizziness, fatigue, or increased heart rate are not typical signs of hypoglycemia. Administering insulin in response to hypoglycemia would further lower blood sugar levels, exacerbating the condition.

5. What is the most important intervention for a client with delirium?

• A. Administer sedative medication
• B. Identify any reversible causes of delirium
• C. Provide a low-stimulation environment
• D. Increase environmental stimulation

Correct answer: B

Rationale: The correct answer is to identify any reversible causes of delirium. Delirium can be caused by various factors such as infections, medications, or metabolic imbalances. Addressing these underlying causes can help resolve delirium. Administering sedative medication (Choice A) can worsen delirium by further altering mental status. Providing a low-stimulation environment (Choice C) is helpful to manage delirium symptoms, but it is not the most important intervention. Increasing environmental stimulation (Choice D) is contraindicated in delirium as it can exacerbate confusion and agitation.

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