Nursing Elites

1. The healthcare provider is assessing a client with a history of congestive heart failure. Which assessment finding would be most concerning?

• A. Shortness of breath on exertion
• B. Weight gain of 2 pounds in a week
• C. Orthopnea
• D. Crackles in the lungs

Correct answer: D

Rationale: Crackles in the lungs are concerning because they indicate pulmonary congestion, a serious complication of congestive heart failure. The presence of crackles suggests fluid accumulation in the lungs, requiring immediate attention to prevent respiratory distress and worsening heart failure. While shortness of breath on exertion, weight gain, and orthopnea are common signs and symptoms of heart failure, crackles specifically point to acute pulmonary edema or worsening congestion, making them the most concerning finding in this scenario.

2. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

• A. Carefully remove the gloves and follow with hand hygiene
• B. Continue with the procedure and clean hands later
• C. Remove the gloves, wash hands, and start over
• D. Use hand sanitizer and continue the procedure

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to carefully remove the gloves and follow with hand hygiene. This is important to prevent potential contamination and maintain infection control practices. Option B is incorrect because cleaning hands later may lead to the spread of potential contaminants. Option C is unnecessary as starting over is not required if proper hand hygiene is performed. Option D is not sufficient in ensuring proper hygiene after a blood spill, as hand sanitizer may not effectively remove all contaminants.

3. The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run over 4 hours for a client who has just delivered a 10-pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The LPN/LVN plans to set the flow rate at how many gtt/min?

• A. 42 gtt/min
• B. 83 gtt/min
• C. 125 gtt/min
• D. 250 gtt/min

Correct answer: B

Rationale: To calculate the flow rate in drops per minute (gtt/min), the formula is Total volume (mL) ÷ Time (min) ÷ Drop factor (gtt/mL). In this case, 1000 mL ÷ 240 min ÷ 20 gtt/mL = 83 gtt/min. Therefore, setting the flow rate to 83 gtt/min ensures the correct administration of the IV fluids and medication. Choices A, C, and D are incorrect as they do not align with the correct calculation based on the provided information.

4. Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility?

• A. Delegates assessment of lung sounds to nursing assistive personnel
• B. Becomes solely responsible for modifying activities of daily living
• C. Consults physical therapy for strengthening exercises in the extremities
• D. Involves respiratory therapy for altered breathing from severe anxiety levels

Correct answer: C

Rationale: Consulting physical therapy for strengthening exercises in the extremities demonstrates a team approach in caring for a patient with mobility issues. Involving other healthcare professionals like physical therapists ensures a comprehensive and specialized approach to address the patient's mobility needs. This collaborative approach benefits the patient by providing specialized interventions. Choices A, B, and D do not exemplify a collaborative team approach. Delegating assessment tasks to nursing assistive personnel (Choice A) may not address the mobility issue directly. Becoming solely responsible for modifying activities of daily living (Choice B) limits the scope of interventions. Involving respiratory therapy for anxiety-related breathing issues (Choice D) addresses a different aspect of care and does not directly target mobility concerns.

5. After a client's death in a long-term care facility, identify the correct sequence of steps for the nurse to perform.

• A. 1) Place a name tag on the body 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body
• B. 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body 1) Place a name tag on the body
• C.
• D.

Correct answer: B

Rationale: The correct sequence of steps for the nurse in a long-term care facility after a client's death is as follows: First, obtain the pronouncement of death from the provider. Second, remove tubes and indwelling lines before proceeding to wash the client's body. Third, ask the client's family members if they would like to view the body. Finally, place a name tag on the body. This order ensures that the necessary procedures are followed with respect and consideration for the deceased client and their family. Choice B is correct. Choices A, C, and D are incorrect as they do not follow the appropriate sequence of actions required in this situation.

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