Nursing Elites

1. The LPN needs to determine the client's respiratory rate. What is the best technique to do this?

• A. Tell the client you need to count their respiratory rate.
• B. Subtly watch the client from across the room when they are doing an activity.
• C. Ask the client to sit still for 30 seconds.
• D. Count respirations while pretending to check the client's pulse.

Correct answer: D

Rationale: The best technique to determine a client's respiratory rate is to count respirations while pretending to check the client's pulse. You should not inform the client that you are counting their respirations, as this might lead to a change in their breathing pattern. Pretending to check the pulse allows you to be close to the client without revealing that you are assessing their respiratory rate. Asking the client to sit still may not be as effective, as it may cause them to concentrate on their breathing. Watching from across the room may not provide an accurate assessment of respirations, as they might be difficult to observe.

2. A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding?

• A. Check the client's temperature.
• B. Report the findings to the nurse-midwife.
• C. Obtain a sample of the amniotic fluid for laboratory analysis.
• D. Document the findings.

Correct answer: D

Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy white fetal skin lubricant. Therefore, the nurse would most appropriately document the findings. Checking the client's temperature, reporting the findings to the nurse-midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary in this situation. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection, while green fluid indicates that the fetus passed meconium before birth. If abnormalities are noted, the nurse should notify the nurse-midwife.

3. When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy?

• A. family history of stroke
• B. ovaries removed before age 45
• C. frequent hot flashes and/or night sweats
• D. unexplained vaginal bleeding

Correct answer: D

Rationale: When considering hormone replacement therapy for a menopausal woman, unexplained vaginal bleeding should be recognized as a contraindication. This is because it could be indicative of a serious underlying condition that needs investigation before initiating hormone therapy. A family history of stroke, by itself, is not a contraindication for hormone replacement therapy, unless the woman herself has a history of stroke or blood-clotting events. Ovaries removed before age 45 may actually increase the likelihood of needing hormone replacement therapy due to early menopause. Frequent hot flashes and night sweats, on the other hand, are symptoms that can be relieved by hormone replacement therapy, making them a potential indication rather than a contraindication.

4. The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include?

• A. Use the defrost setting on microwave ovens to warm bottles.
• B. When refrigerating formula, discard partially used bottles after 24 hours.
• C. When using formula concentrate, mix one part concentrate and two parts water.
• D. If a portion of one bottle is left for the next feeding, discard it.

Correct answer: B

Rationale: The correct answer is to use the defrost setting on microwave ovens to warm bottles. It is crucial to be cautious when heating bottles in a microwave to prevent milk from becoming superheated. The defrost setting is recommended, and the formula's temperature should always be checked before feeding the baby. Choice B, which advises to discard partially used bottles of refrigerated formula after 24 hours, is also correct. This is important to prevent the introduction of pathogens by the baby into the formula. Choice C, recommending mixing one part formula concentrate with two parts water, is essential for ensuring the correct dilution. Choice D, suggesting to discard any remaining portion of a bottle for the next feeding, is incorrect. It is not necessary to discard the remaining portion if it has been refrigerated promptly and used within a safe time frame. Adding fresh formula to a partially used bottle is not recommended, as it can lead to the growth of pathogens that may be transferred to the new formula.

5. A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be?

• A. Harsh
• B. Hollow
• C. Tubular
• D. Rustling

Correct answer: D

Rationale: The correct answer is D: 'Rustling.' Vesicular breath sounds are described as rustling and resemble the sound of wind blowing through trees. Harsh, hollow, and tubular sounds are associated with bronchial (tracheal) breath sounds, not vesicular breath sounds. Harsh sounds are high-pitched, hollow sounds are reverberating, and tubular sounds are like blowing air into a tube. Therefore, options A, B, and C are incorrect descriptions of vesicular breath sounds and are more characteristic of bronchial breath sounds.

Similar Questions