Nursing Elites

1. Postoperatively, signs of hemorrhagic shock are observed. The nurse notifies the surgeon, who instructs to continue monitoring vitals every 15 minutes and report back in one hour. What should the nurse do next?

• A. Notify the nurse manager
• B. Continue monitoring as instructed
• C. Administer IV fluids as per protocol
• D. Prepare for immediate transfer to the ICU

Correct answer: B

Rationale: The correct answer is to continue monitoring the patient as instructed. This is crucial to assess the patient's condition and response to initial interventions. Administering IV fluids or preparing for transfer to the ICU should only be done based on further assessment or explicit orders from the healthcare provider. Notifying the nurse manager, as suggested in choice A, without further assessment or intervention could delay immediate patient care and management.

2. 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.

3. When orienting a newly licensed nurse on taking a telephone prescription, which statement indicates understanding of the process?

• A. A second nurse enters the prescription into the client’s medical record.
• B. Another nurse should listen to the phone call.
• C. The provider can clarify the prescription when they sign the health record.
• D. I should omit the 'read back' if this is a one-time prescription.

Correct answer: A

Rationale: The correct answer is A because a second nurse should verify and enter the prescription into the client’s medical record to ensure accuracy. This step is crucial to prevent errors in transcription and administration. Choice B is incorrect as having another nurse listen to the phone call does not ensure accurate transcription. Choice C is incorrect because the provider clarifying the prescription upon signing the health record does not replace the need for proper documentation. Choice D is incorrect because the 'read back' process is essential for all telephone prescriptions to confirm accuracy and prevent errors in transcription or administration.

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 nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse about an older adult client who has shingles. Which of the following information should the nurse include in the report?

• A. Where the client ate his breakfast
• B. The times for routine vital sign measurements
• C. The exact times the client had visitors
• D. The type of transmission-based precautions in place

Correct answer: D

Rationale: Information about transmission-based precautions is essential for infection control and continuity of care.

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