Nursing Elites

1. Which of the following symptoms is not indicative of autonomic dysreflexia in the client with a spinal cord injury?

• A. sudden onset of headache
• B. flushed face
• C. hypotension
• D. nasal congestion

Correct answer: C

Rationale: Autonomic dysreflexia is characterized by a sudden onset of symptoms due to an overactive autonomic nervous system. Hypotension is not indicative of autonomic dysreflexia; instead, hypertension is a hallmark sign. Therefore, hypotension is the correct answer. Flushed face, sudden onset of headache, and nasal congestion are classic symptoms of autonomic dysreflexia caused by a noxious stimulus below the level of the spinal cord injury. These symptoms result from the body's attempt to regulate blood pressure when the normal feedback loop is interrupted.

2. The nurse uses prioritization to determine all of the following except:

• A. time allotment for certain tasks.
• B. appropriate interventions.
• C. treatment procedures.
• D. the need for client education.

Correct answer: C

Rationale: The correct answer is C: "treatment procedures." Prioritization in nursing involves determining the order of importance or urgency of tasks. Treatment procedures are standards of care that need to be followed as defined by the facility or nursing unit. They are not typically subject to prioritization but are mandatory based on established protocols. Time allotment for certain tasks, appropriate interventions, and the need for client education are all aspects that can be influenced by prioritization. For instance, prioritizing tasks helps in managing time effectively, selecting the most suitable interventions, and identifying the necessity for client education as part of the care plan.

3. When documenting in the client’s record, what type of information should be recorded?

• A. educated predictions of outcomes
• B. personal opinions
• C. objective information
• D. subjective information

Correct answer: C

Rationale: When documenting in a client's record, it is crucial to record objective information. Objective information is factual, based on observations and measurable data. This type of information is essential for accurate and effective communication among healthcare professionals involved in the client's care. Choices A and B, educated predictions of outcomes and personal opinions, are subjective in nature and may not provide an accurate representation of the client's condition. Choice D, subjective information, includes personal feelings, interpretations, and opinions, which are not ideal for documentation as they can be biased and unreliable.

4. The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?

• A. The LPN elevates the head of the bed by at least 30 degrees.
• B. If the residual is greater than 200mL, the LPN should not administer the enteral feeding.
• C. The LPN should discard the residual before administering the tube feeding.
• D. The residual pH level is tested to ensure appropriate placement.

Correct answer: C

Rationale: The incorrect step is choice C. The residual should be discarded before administering the tube feeding. Discarding the residual is essential to prevent contamination and ensure accurate measurement of the enteral feeding. Elevating the head of the bed by at least 30 degrees (choice A) is correct as it helps prevent aspiration during feeding. Testing the pH level of the residual (choice D) ensures proper placement of the tube. Withholding feeding if the residual is greater than 200mL (choice B) is crucial to prevent overfeeding, making this statement correct.

5. The healthcare professional seeks to assess the renal function of an elderly client who is about to receive a nephrotoxic medication. Which of the following labs provides the best indicator for renal function?

• A. urinalysis
• B. creatinine and blood urea nitrogen
• C. chemistry of electrolytes
• D. creatinine clearance

Correct answer: D

Rationale: In the context of an elderly client, assessing renal function before administering a nephrotoxic medication is crucial. While urinalysis and blood urea nitrogen provide valuable information on hydration status and overall health clues, they are not specific indicators of renal function. The chemistry of electrolytes may show abnormalities in renal failure, but it does not directly measure the kidneys' ability to eliminate waste. Creatinine clearance, on the other hand, is considered the best indicator for renal function in the elderly. This test accounts for decreases in lean body mass that can affect blood creatinine levels and is widely used to estimate the glomerular filtration rate, reflecting the kidneys' filtration capability. Therefore, creatinine clearance is the most appropriate lab test to assess renal function in this scenario.

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