Nursing Elites

1. A nurse receives a report about a client receiving IV fluids infusing at 125 mL/hr but notes they have only received 80 mL over the last 2 hours. What should the nurse do first?

• A. Check IV tubing for obstruction
• B. Increase the flow rate
• C. Change the IV site
• D. Notify the physician

Correct answer: A

Rationale: The correct first action for the nurse to take is to check the IV tubing for obstruction. This step is crucial in ensuring that the IV fluids are flowing properly and that there are no blockages preventing the correct infusion rate. Increasing the flow rate (Choice B) without confirming the tubing's status could lead to potential complications if there is indeed an obstruction. Changing the IV site (Choice C) is not the priority in this situation unless there are specific clinical indications. Notifying the physician (Choice D) can be done after checking the tubing for obstruction, as the physician may need to be informed depending on the findings.

2. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client?

• A. "Rashes are very common, especially if you have dry skin. Did it go away on its own?"
• B. "Virtually all medications have adverse effects. It sounds like this could have been an adverse effect of the antibiotic."
• C. "It's unlikely that your doctor will prescribe an antibiotic for what seems to be a minor viral infection, so we shouldn't be concerned about that rash."
• D. "We need to document the exact medication you were taking because you might be allergic to it."

Correct answer: D

Rationale: The correct answer is D. If a client reports developing a rash when taking a specific medication, even if they are not aware of any allergies, it is crucial to document this information. This is necessary to prevent future allergic reactions. Identifying the exact medication that caused the rash is essential as the client could have an allergy to it. Providing this information allows healthcare providers to avoid prescribing the same medication again, which could potentially lead to more severe allergic reactions or life-threatening situations. Choices A, B, and C are incorrect because they do not address the importance of documenting the specific medication that caused the adverse reaction or the potential risks of repeating the medication. Simply attributing the rash to common occurrences, adverse effects of medications in general, or assuming the rash is insignificant in the current context can overlook the critical aspect of identifying and avoiding allergens.

3. A nurse discovers a small paper fire in a trash can in a client’s bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take?

• A. Open the windows in the client’s room to allow smoke to escape.
• B. Obtain a class C fire extinguisher to extinguish the fire.
• C. Remove all electrical equipment from the client’s room.
• D. Place wet towels along the base of the door to the client’s room.

Correct answer: B

Rationale: The correct answer is B: Obtain a class C fire extinguisher to extinguish the fire. Using a class C fire extinguisher is appropriate for electrical fires, which can include fires involving electrical equipment or appliances. In this scenario, a paper fire in a trash can in the client's bathroom could potentially involve electrical components, making a class C fire extinguisher the most suitable choice. Option A, opening the windows, may help with ventilation but does not address the fire directly. Option C, removing electrical equipment, is a precautionary measure but does not address the immediate fire hazard. Option D, placing wet towels along the base of the door, is a strategy to prevent smoke from entering the room but does not extinguish the fire.

4. The LPN is instructing a client with high cholesterol about diet and lifestyle modifications. What comment from the client indicates that the teaching has been effective?

• A. If I exercise at least twice weekly for one hour, I will lower my cholesterol.
• B. I need to avoid eating proteins, including red meat.
• C. I will limit my intake of beef to 4 ounces per week.
• D. My blood level of low-density lipoproteins needs to increase.

Correct answer: C

Rationale: The correct answer is C. Limiting intake of beef to 4 ounces per week is an effective dietary modification to manage high cholesterol. Choice A is incorrect because the frequency and duration of exercise alone may not be sufficient to lower cholesterol significantly. Choice B is incorrect as proteins, including lean sources like poultry and fish, can be a part of a healthy diet. Choice D is incorrect as low-density lipoproteins, known as bad cholesterol, should be decreased, not increased, for heart health.

5. When should discharge planning for a patient admitted to the neurological unit with a diagnosis of stroke begin?

• A. At the time of admission
• B. The day before the patient is to be discharged
• C. When outpatient therapy is no longer needed
• D. As soon as the patient's discharge destination is known

Correct answer: A

Rationale: Discharge planning for a patient admitted to the neurological unit with a stroke diagnosis should begin at the time of admission. Initiating discharge planning early allows for a comprehensive assessment of the patient's needs, enables better coordination of care, and ensures a smooth transition from the hospital to the next level of care. Option B is incorrect because waiting until the day before discharge does not provide enough time for adequate planning. Option C is incorrect because waiting until outpatient therapy is no longer needed delays the planning process. Option D is incorrect because waiting until the discharge destination is known may result in rushed planning and inadequate preparation for the patient's needs.

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