Nursing Elites

1. During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the LPN/LVN implement?

• A. Provide additional coffee on the client's breakfast tray.
• B. Exchange the client's grape juice for cranberry juice.
• C. Bring the client additional fruit at mid-morning.
• D. Encourage additional oral intake of juices and water.

Correct answer: D

Rationale: Encouraging additional oral intake of juices and water is the appropriate intervention in this scenario. Dark amber urine can indicate concentrated urine due to dehydration or other factors. By encouraging more fluids, the LPN/LVN can help dilute the urine, reducing the concentration of pigments causing the dark color. Providing additional coffee (Choice A) would not necessarily increase hydration and could potentially have a diuretic effect. Exchanging grape juice for cranberry juice (Choice B) does not address the core issue of hydration. Bringing additional fruit (Choice C) may provide some fluid, but encouraging specific fluids like juices and water would be more effective in diluting the urine.

2. A client with a history of seizures is prescribed phenytoin (Dilantin). What side effect should the healthcare provider report immediately?

• A. Increased appetite
• B. Dry mouth
• C. Nausea and vomiting
• D. Gingival hyperplasia

Correct answer: D

Rationale: Gingival hyperplasia is a significant side effect associated with phenytoin therapy. It is characterized by an overgrowth of gum tissue, which can lead to issues such as difficulty in speaking, eating, and maintaining proper oral hygiene. This condition can progress rapidly and may require immediate intervention by the healthcare provider to prevent further complications. Increased appetite, dry mouth, and nausea/vomiting are common side effects of various medications, but they are not as urgent or serious as gingival hyperplasia in a client taking phenytoin.

3. A healthcare provider is assessing a client with a diagnosis of acute pancreatitis. Which laboratory value would be most concerning?

• A. Serum amylase of 200 U/L
• B. Serum lipase of 250 U/L
• C. Blood glucose of 200 mg/dL
• D. Serum calcium of 7.5 mg/dL

Correct answer: D

Rationale: In acute pancreatitis, hypocalcemia (low serum calcium) is a critical finding that is associated with a poor prognosis and requires immediate attention. Serum amylase and lipase are typically elevated in acute pancreatitis due to pancreatic inflammation, but they are not indicators of severity. Blood glucose levels may be elevated due to stress or underlying conditions but are not directly related to the severity of acute pancreatitis. Therefore, the most concerning value in this scenario is the low serum calcium level, which can have significant implications for the client's prognosis.

4. A healthcare professional is collecting data to evaluate a middle adult's psychosocial development. The healthcare professional should expect middle adults to demonstrate which of the following developmental tasks? (Select ONE that does not apply.)

• A. Develop an acceptance of diminished strength and increased dependence on others.
• B. Spend time focusing on improving job performance.
• C. Welcome opportunities to be creative and productive.
• D. Commit to finding friendship and companionship.

Correct answer: A

Rationale: Middle adulthood is a stage where individuals typically focus on various developmental tasks. Option A is incorrect as middle adults do not necessarily develop an acceptance of diminished strength and increased dependence on others; they often strive to maintain independence. Option B is correct as middle adults are usually focused on improving job performance and advancing their careers. Option C is correct as middle adults tend to welcome opportunities to be creative and productive, engaging in new hobbies or projects. Option D is correct as middle adults often commit to finding friendship and companionship as they value social connections and support networks. Therefore, options B, C, and D are the expected developmental tasks for middle adults, making them the correct choices.

5. A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

• A. Protective environment
• B. Airborne precautions
• C. Droplet precautions
• D. Contact precautions

Correct answer: D

Rationale: The correct answer is D: Contact precautions. When a client has an abdominal wound with purulent drainage, contact precautions are necessary to prevent the spread of infection through direct contact. Protective environment precautions are used for immunocompromised clients, airborne precautions are for diseases transmitted by airborne particles, and droplet precautions are for diseases transmitted by respiratory droplets. In this case, the focus is on preventing direct contact transmission, making contact precautions the most appropriate choice. Protective environment, airborne, and droplet precautions are not indicated in this scenario because the primary concern is the direct contact transmission of pathogens through the wound drainage.

Similar Questions