Nursing Elites

1. The LPN/LVN is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which observation indicates that the client is experiencing oxygen toxicity?

• A. Nasal congestion
• B. Cough
• C. Sore throat
• D. Fatigue

Correct answer: C

Rationale: The correct answer is 'C: Sore throat.' Oxygen toxicity can manifest with symptoms like a sore throat, cough, chest pain, difficulty breathing, and fatigue. However, a sore throat can be an early indicator of oxygen toxicity and should prompt immediate attention. Nasal congestion, cough, and fatigue are not specific indicators of oxygen toxicity but could be related to other factors in a client with COPD receiving oxygen therapy.

2. The nurse is caring for a client with hyperthyroidism. Which finding should the nurse expect to observe in this client?

• A. Weight loss
• B. Cold intolerance
• C. Bradycardia
• D. Dry skin

Correct answer: A

Rationale: Weight loss is a common finding in clients with hyperthyroidism due to increased metabolic activity. Hyperthyroidism leads to an overactive thyroid gland, which results in an increased metabolic rate and often leads to weight loss despite a normal or increased appetite. Cold intolerance (Choice B) is more commonly associated with hypothyroidism, where the body's processes slow down. Bradycardia (Choice C) is a slow heart rate, which is not typically seen in hyperthyroidism; rather, tachycardia or an increased heart rate is more common. Dry skin (Choice D) is also not a typical finding in hyperthyroidism, as the skin is more likely to be warm and moist due to increased metabolic activity.

3. A client has an order for 1000 ml of D5W over an 8-hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?

• A. Ask the client if there are any breathing problems
• B. Have the client void as much as possible
• C. Check the vital signs
• D. Auscultate the lungs

Correct answer: D

Rationale: The correct answer is D: Auscultate the lungs. When a significant amount of fluid has been infused, especially in a short period, it is crucial to assess for signs of fluid overload or pulmonary complications, such as crackles or decreased breath sounds. This can be achieved by auscultating the lungs. Choice A, asking the client about breathing problems, may provide valuable information, but direct assessment through auscultation takes priority. Choice B, having the client void, and Choice C, checking vital signs, are important nursing actions but are not as urgent as assessing the lungs for potential complications in this scenario.

4. A client with a terminal illness is expected to pass away within 24 hours. The family asks the nurse about what to expect at this time. Which of the following findings should the nurse include?

• A. Regular breathing pattern
• B. Warm extremities
• C. Increased urine output
• D. Decreased muscle tone

Correct answer: D

Rationale: As death approaches, decreased muscle tone and other signs like decreased blood pressure, irregular breathing patterns, cold extremities, and decreased urine output are common. Warm extremities (choice B) would not be expected as circulation may be compromised. Increased urine output (choice C) is unlikely as organ function declines. A regular breathing pattern (choice A) is also unlikely as irregular breathing patterns are common near death.

5. Which of the following manifestations confirms the presence of pediculosis capitis in students?

• A. Scratching the head more than usual
• B. Flakes evident on a student's shoulders
• C. Oval pattern occipital hair loss
• D. Whitish oval specks sticking to the hair

Correct answer: D

Rationale: The correct answer is D. Whitish oval specks sticking to the hair shaft are nits, which are a definitive sign of pediculosis capitis (head lice). A: Scratching the head more than usual is a common symptom but not confirmatory of head lice infestation. B: Flakes evident on a student's shoulders may indicate dandruff or dry scalp, not necessarily head lice. C: Oval pattern occipital hair loss is not a typical manifestation of pediculosis capitis.

Similar Questions