Nursing Elites

1. The healthcare provider is caring for a client with a history of atrial fibrillation. Which assessment finding would be most concerning?

• A. Blood pressure of 150/90 mmHg
• B. Irregular heart rhythm
• C. Shortness of breath
• D. Fatigue

Correct answer: C

Rationale: Shortness of breath is the most concerning assessment finding in a client with a history of atrial fibrillation. It can indicate a worsening of the condition, pulmonary edema, or the development of a complication such as heart failure. A blood pressure of 150/90 mmHg, while elevated, is not as immediately concerning as respiratory distress in this context. An irregular heart rhythm is expected in atrial fibrillation and may not necessarily be a new or concerning finding. Fatigue is a common symptom in atrial fibrillation but is not as acutely concerning as shortness of breath, which may indicate compromised oxygenation and circulation.

2. When planning care for a newly admitted elderly client who is severely dehydrated, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?

• A. Converse with the client to determine if the mucous membranes are impaired
• B. Report hourly outputs of less than 30 ml/hr
• C. Monitor client's ability to move in the bed
• D. Check skin turgor every 4 hours

Correct answer: B

Rationale: The correct answer is B. Assigning the UAP to report hourly outputs of less than 30 ml/hr is appropriate as it falls within their scope of practice and does not involve making clinical assessments or decisions. Choices A, C, and D involve tasks that require a higher level of clinical judgment and training. Choice A requires assessing mucous membranes, which is beyond the UAP's scope. Choice C involves assessing movement ability, which requires more specialized training. Choice D involves assessing skin turgor, which also requires a higher level of clinical judgment.

3. A client has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

• A. Droplet
• B. Contact
• C. Airborne
• D. Protective

Correct answer: A

Rationale: Pharyngeal diphtheria is transmitted via droplets, primarily through respiratory secretions. Therefore, droplet precautions are necessary to prevent the spread of the infection. Droplet precautions involve wearing a surgical mask, goggles, and a gown when within three feet of the client. Contact precautions are used for diseases transmitted by direct or indirect contact; airborne precautions are for diseases transmitted through airborne particles; protective precautions are not a standard precaution type.

4. The nurse is caring for an older adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?

• A. Encourage the patient to perform as many self-care activities as possible.
• B. Provide assistance with a bed bath to promote patient comfort.
• C. Coordinate with physical therapy for gait training.
• D. Instruct the patient to remain on bed rest to prevent fatigue.

Correct answer: A

Rationale: The correct answer is A: Encourage the patient to perform as many self-care activities as possible. For a patient who has had a stroke, promoting independence and engaging in self-care activities help maintain mobility and foster a sense of autonomy. Choices B, C, and D are incorrect because providing assistance with a bed bath, coordinating with physical therapy for gait training, or advising bed rest without indications may not be the best interventions for promoting optimal recovery and independence in a stroke patient.

5. The healthcare provider is caring for a client receiving chemotherapy. Which finding should the LPN/LVN report to the healthcare provider immediately?

• A. Mild nausea
• B. Hair loss
• C. Increased fatigue
• D. Fever of 101.5°F (38.6°C)

Correct answer: D

Rationale: A fever of 101.5°F (38.6°C) in a client undergoing chemotherapy is a significant finding that may indicate an underlying infection, which can be life-threatening due to the client's compromised immune system. Prompt reporting and intervention are crucial to prevent complications. Mild nausea, hair loss, and increased fatigue are common side effects of chemotherapy and are expected findings that do not typically require immediate reporting unless they are severe or significantly impacting the client's well-being. Therefore, the LPN/LVN should prioritize reporting the fever over the other options.

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