Nursing Elites

1. The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?

• A. a 63-year-old female undergoing chemotherapy for breast cancer
• B. a 56-year-old female with dementia undergoing a swallow study
• C. a 34-year-old male with a PEG tube newly admitted for diabetic ketoacidosis
• D. a 45-year-old male recovering from a knee replacement under general anesthesia

Correct answer: D

Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected due to the effects of the anesthesia on gut motility. For the other clients, hearing less than 5 bowel sounds per minute would indicate an abnormal finding. In the context of the given situation, the client recovering from knee replacement surgery aligns with the expected range of bowel sounds post-general anesthesia. Therefore, choice D is the correct answer. Choices A, B, and C present scenarios where hearing less than 5 bowel sounds per minute would be abnormal, indicating potential issues that need further evaluation.

2. Ethical and moral issues concerning restraints include all of the following except:

• A. emotional impact on the client and family
• B. dignity of the client
• C. client's quality of life
• D. policies and procedures

Correct answer: D

Rationale: The correct answer is 'policies and procedures.' While policies and procedures are important for guidance and structure, they do not inherently involve ethical or moral considerations. The emotional impact on the client and family, the dignity of the client, and the client's quality of life are all directly related to ethical and moral concerns when it comes to the use of restraints. These factors are crucial in ensuring that the use of restraints is not only physically necessary but also ethically justifiable and respects the individual's rights and well-being. Therefore, options A, B, and C are all aspects that touch upon ethical and moral dimensions in the context of restraints.

3. The nurse is teaching a client about communicable diseases and explains that a portal of entry is:

• A. a vector.
• B. a source, like contaminated water.
• C. food.
• D. the respiratory system.

Correct answer: D

Rationale: The correct answer is 'the respiratory system.' A portal of entry is the path through which a microorganism enters the body. In the case of communicable diseases, the respiratory system can serve as a portal of entry for pathogens such as viruses or bacteria. Choices A, B, and C are incorrect. A 'vector' is an organism that transmits disease, not the entry point for pathogens. Contaminated water or food can act as sources or reservoirs of disease-causing microorganisms, not portals of entry.

4. A nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which is the most appropriate action for the nurse to take?

• A. Report the incident to the nursing supervisor
• B. Confront the nurse who gave the enema and inform the nurse that she may face charges of battery
• C. Tell the client that the nurse did the right thing in giving the enema
• D. Contact the client's health care provider

Correct answer: A

Rationale: Battery is any intentional touching of a client without the client's consent, which violates the client's rights. If a nurse discovers such an incident, they should report it to the nursing supervisor. Confronting the nurse and threatening charges of battery could lead to unnecessary conflict. Telling the client that the nurse did the right thing is incorrect as it goes against the client's wishes. While the health care provider may need to be notified eventually, the first step should be reporting the incident to the nursing supervisor to address the violation appropriately.

5. What sign might the nurse observe in a client with a high ammonia level?

• A. coma
• B. edema
• C. hypoxia
• D. polyuria

Correct answer: A

Rationale: Coma is a sign that a nurse might observe in a client with a high ammonia level. Elevated ammonia levels can lead to hepatic encephalopathy, a condition characterized by impaired brain function, which can progress to coma. Edema (choice B) is swelling caused by excess fluid trapped in body tissues, not typically associated with high ammonia levels. Hypoxia (choice C) is a condition of inadequate oxygen supply to tissues and is not directly related to high ammonia levels. Polyuria (choice D) refers to excessive urination and is not a typical sign of high ammonia levels.

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