Nursing Elites

1. The client is receiving total parenteral nutrition (TPN). Which laboratory value should the LPN/LVN monitor closely to assess for complications?

• A. Serum potassium
• B. Blood glucose
• C. Serum sodium
• D. Serum calcium

Correct answer: B

Rationale: The correct answer is B: Blood glucose. When caring for a client receiving total parenteral nutrition (TPN), monitoring blood glucose levels is essential due to the risk of hyperglycemia. TPN solutions are high in glucose, and clients may be at risk of developing hyperglycemia if the infusion rate is too high or if there are underlying issues such as insulin resistance. Monitoring serum potassium (choice A) is important but not the most crucial value to monitor in clients receiving TPN. Serum sodium (choice C) and serum calcium (choice D) are not directly impacted by TPN administration and are less likely to be affected compared to blood glucose levels.

2. When changing a client's colostomy pouch and noticing peristomal skin irritation, which of the following actions should the nurse take?

• A. Change the pouch as needed based on individual requirements.
• B. Apply the pouch only when the skin barrier is completely dry.
• C. Pat the peristomal skin dry after cleaning.
• D. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma.

Correct answer: D

Rationale: When a nurse observes peristomal skin irritation while changing a client's colostomy pouch, it is crucial to ensure that the pouch is slightly larger (0.32 cm or 1/8 inch) than the stoma. This extra space helps prevent the pouch from rubbing against the stoma and causing further irritation. Option A is correct because colostomy pouches should be changed based on individual needs, not necessarily every 24 hours. Option B is incorrect because applying the pouch only when the skin barrier is completely dry ensures better adhesion. Option C is incorrect as patting the peristomal skin dry after cleaning is more gentle and less likely to cause irritation compared to rubbing.

3. A client diagnosed with a terminal illness asks the nurse about the nurse’s religious beliefs related to death and dying. An appropriate nursing response is to:

• A. Share personal beliefs
• B. Encourage the client to express their thoughts about death and dying
• C. Redirect the conversation to medical treatment
• D. Inform the client that the nurse’s beliefs are not relevant

Correct answer: B

Rationale: Encouraging the client to express their own thoughts about death and dying is an appropriate nursing response in this situation. It allows the client to explore and express their feelings, fears, and beliefs, facilitating a therapeutic conversation. Sharing personal beliefs (choice A) may not be appropriate as it could impose the nurse's beliefs on the client and hinder open discussion. Redirecting the conversation to medical treatment (choice C) may avoid addressing the client's emotional and spiritual needs. Informing the client that the nurse’s beliefs are not relevant (choice D) dismisses the client's concerns and does not encourage open communication.

4. Twenty minutes after starting a heat application, the client mentions that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN?

• A. That indicates you have derived the maximum benefit, and the heat can be removed.
• B. Your blood vessels are dilating and removing the heat from the site.
• C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
• D. The body's receptors adapt over time as they are exposed to heat.

Correct answer: D

Rationale: Choice D is the correct response. The body's receptors adapt to the heat over time, which can explain why the client no longer perceives the warmth from the heating pad. This phenomenon is known as thermal adaptation. Choices A, B, and C are incorrect. Choice A is inaccurate because the client not feeling the warmth does not necessarily mean they have derived the maximum benefit. Choice B incorrectly states that blood vessels dilating remove heat, which is not accurate. Choice C suggests increasing the temperature when the pad no longer feels warm, which could potentially lead to burns or discomfort for the client.

5. A client is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

• A. Reassure the client that this is an expected response to grief.
• B. Ignore the client’s anger and continue with the plan of care.
• C. Tell the client that anger is not going to help his situation.
• D. Encourage the client to express his anger.

Correct answer: A

Rationale: When a client is expressing anger about a diagnosis, it is essential for the nurse to validate the client's feelings. Choice A is correct because reassuring the client that anger is an expected response to grief acknowledges the client's emotions and encourages expression, fostering a therapeutic relationship. This validation helps the client feel understood and supported during a challenging time. Choice B is incorrect as ignoring the client's anger can lead to feelings of neglect and hinder effective communication, which is crucial for providing holistic care. Choice C is inappropriate because telling the client that anger is not helpful dismisses the client's emotions and can further escalate the situation, potentially damaging the nurse-client relationship. Choice D is not the best option as it does not involve acknowledging the client's feelings or providing support and validation, which are vital in promoting emotional well-being and trust between the client and the nurse.

Similar Questions