Nursing Elites

1. The client with a diagnosis of chronic heart failure is receiving discharge teaching. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself every day at the same time.
• B. I will call my doctor if my legs swell more.
• C. I will take my water pill only when I feel short of breath.
• D. I will limit the amount of salt in my diet.

Correct answer: C

Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to help manage fluid retention in chronic heart failure. This statement indicates a need for further teaching as the client needs to understand the importance of consistent medication adherence. Choices A, B, and D demonstrate good understanding of self-care management in heart failure, including daily weight monitoring, prompt reporting of worsening symptoms to the healthcare provider, and dietary sodium restriction, respectively.

2. A healthcare professional is preparing to administer IV fluids to a client. The professional notes sparks when plugging in the IV pump. Which of the following actions should the professional take first?

• A. Label the pump with a defective equipment sticker.
• B. Unplug the pump.
• C. Obtain a replacement pump.
• D. Notify the maintenance department to fix the pump.

Correct answer: B

Rationale: Unplugging the pump is the correct initial action in this situation to prevent any potential fire hazards. Sparks when plugging in the IV pump indicate an electrical issue that can lead to a fire. By immediately unplugging the pump, the healthcare professional ensures the safety of the client and prevents any further risks. Labeling the pump with a defective equipment sticker (Choice A) is not the priority as the immediate concern is safety. Obtaining a replacement pump (Choice C) can be considered after addressing the safety issue. Notifying the maintenance department (Choice D) is important but should follow the immediate action of unplugging the pump to mitigate the risk.

3. A client with diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the LPN/LVN to take?

• A. Encourage the client to increase fluid intake.
• B. Monitor the client's blood glucose level.
• C. Administer insulin as prescribed.
• D. Assess the client's urine output.

Correct answer: B

Rationale: The correct answer is to monitor the client's blood glucose level. When a client with diabetes mellitus presents with symptoms of polyuria, polydipsia, and polyphagia, it indicates hyperglycemia. Monitoring blood glucose levels is crucial to assess and manage the client's condition effectively. Option A, encouraging the client to increase fluid intake, may exacerbate polyuria. Option C, administering insulin, should be done based on the healthcare provider's prescription after assessing the blood glucose level. Option D, assessing the client's urine output, is important but not the most immediate action needed in this scenario; monitoring blood glucose levels takes precedence.

4. A caregiver of an immobile client requiring assistance with repositioning is being taught by a nurse on preventing back strain. Which statement by the caregiver indicates an understanding of the teaching?

• A. I will place the bed in the lowest position
• B. I will tighten my abdominal muscles prior to moving
• C. I will keep my legs straight to provide more power in the lift
• D. I will twist at the waist while pulling the draw sheet

Correct answer: B

Rationale: The correct answer is B. Tightening the abdominal muscles before moving helps protect the back by providing core support. Keeping the legs straight (choice C) is incorrect as bending the legs is recommended to provide a stable base and prevent strain on the back. Twisting at the waist (choice D) while moving can cause back injury due to the strain on the spine. Placing the bed in the lowest position (choice A) is not directly related to preventing back strain during client repositioning, although it may be necessary for other reasons.

5. A client is being treated for pneumonia and is receiving intravenous antibiotics. The nurse notes that the client has developed a rash and is complaining of itching. Which of the following is the most appropriate initial nursing action?

• A. Administer diphenhydramine (Benadryl)
• B. Discontinue the antibiotic infusion
• C. Apply a cool compress to the rash
• D. Notify the healthcare provider

Correct answer: B

Rationale: The most appropriate initial nursing action when a client develops a rash and itching while receiving intravenous antibiotics is to discontinue the antibiotic infusion. This is crucial to prevent further allergic reactions. Administering diphenhydramine (Benadryl) (Choice A) can be considered after discontinuing the antibiotic infusion. Applying a cool compress to the rash (Choice C) may provide symptomatic relief but does not address the underlying cause. Notifying the healthcare provider (Choice D) is important but should come after discontinuing the antibiotic infusion to ensure the client's safety.

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