Nursing Elites

1. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is MOST critical for the nurse to include in the plan of care?

• A. Hourly urine output
• B. White blood cell count
• C. Blood glucose every 4 hours
• D. Temperature every 2 hours

Correct answer: A

Rationale: Monitoring hourly urine output is crucial after successful resuscitation from a pulseless dysrhythmia to assess kidney function and perfusion. The kidneys are particularly vulnerable to injury following cardiac events due to decreased perfusion during the event. Evaluating urine output hourly allows for early detection of renal impairment or inadequate organ perfusion. Option B, monitoring white blood cell count, is not a priority in this situation as it does not directly relate to immediate post-resuscitation care. Option C, checking blood glucose every 4 hours, is important but not as critical as assessing kidney function and perfusion. Option D, measuring temperature every 2 hours, is relevant for monitoring signs of infection or inflammatory response but is not as crucial as assessing kidney function in this scenario.

2. Upon completing the admission documents, the nurse learns that the 87-year-old client does not have an advance directive. What action should the nurse take?

• A. Record the lack of advance directive on the chart
• B. Give information about advance directives
• C. Assume that the client wishes a full code
• D. Refer this issue to the unit secretary

Correct answer: B

Rationale: The correct action for the nurse to take is to give information about advance directives to the client. By providing this information, the nurse empowers the client to make an informed decision about their care preferences. Choice A is incorrect because simply recording the lack of advance directive does not address the client's need for information. Choice C is incorrect because assuming the client wishes a full code without discussing it with them is not appropriate and may not align with the client's wishes. Choice D is incorrect as the nurse should directly address the issue with the client rather than involving another staff member.

3. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

• A. Notify the nursing manager.
• B. Document the client's condition and communication with the surgeon.
• C. Administer additional fluids as per standard procedure.
• D. Call the surgeon back immediately to ensure timely intervention.

Correct answer: B

Rationale: In this scenario, the nurse should choose option B, which is to document the client's condition and communication with the surgeon. By documenting the client's condition and the communication with the surgeon, the nurse ensures legal protection and maintains continuity of care. This documentation serves as evidence of the actions taken, communication exchanged, and the rationale behind decisions made. Option A, notifying the nursing manager, may not be necessary at this stage unless there are specific institutional protocols requiring it. Administering additional fluids without further clarification may not be appropriate and could worsen the client's condition if not indicated. Calling the surgeon back immediately (option D) may disrupt the agreed-upon plan of action and fail to follow the surgeon's instructions of reassessment after an hour.

4. A client with chronic renal failure selects scrambled eggs for breakfast. What action should the LPN/LVN take?

• A. Commend the client for selecting a high biological value protein.
• B. Remind the client that protein in the diet should be avoided.
• C. Suggest that the client also select orange juice to promote absorption.
• D. Encourage the client to attend classes on dietary management of chronic renal failure.

Correct answer: A

Rationale: The correct action is to commend the client for selecting a high biological value protein, as scrambled eggs provide a good protein source for clients with chronic renal failure. Protein is essential for maintaining muscle mass and overall health in these clients. Reminding the client to avoid protein is incorrect as it may lead to protein-energy malnutrition, which is a common concern in chronic renal failure. Suggesting orange juice for absorption is not relevant to the situation, as protein absorption is not a primary concern in this context. Encouraging the client to attend classes on dietary management of chronic renal failure is important for overall education but is not the immediate action needed in response to the client's breakfast choice.

5. When assessing a patient's feet, the nurse notices that the toenails are thick and separated from the nail bed. What does the nurse most likely suspect is the cause of this condition?

• A. Fungi
• B. Friction
• C. Nail polish
• D. Nail polish remover

Correct answer: A

Rationale: The nurse would most likely suspect fungi as the cause of thickened and separated toenails. Fungal infections can lead to changes in the nail structure, causing them to thicken and separate from the nail bed. Friction, nail polish, and nail polish remover are less likely to cause these specific nail changes. Friction typically leads to calluses or blisters, while nail polish and nail polish remover do not commonly result in thickened and separated toenails.

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