Nursing Elites

1. While measuring a client’s vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?

• A. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart
• B. Measure the blood pressure
• C. Perform an ECG
• D. Recheck the heart rate after 5 minutes

Correct answer: A

Rationale: The appropriate nursing action when an irregularity in the heart rate is observed is to count the apical pulse rate for a full minute and describe the rhythm in the chart. This approach helps in obtaining an accurate assessment of the irregularities present. Measuring the blood pressure (Choice B) is important but not the immediate priority when an irregular heart rate is noted. Performing an ECG (Choice C) may be necessary but is a more advanced intervention that should follow the initial assessment. Rechecking the heart rate after 5 minutes (Choice D) may delay potential interventions for addressing the irregularity, making it less appropriate than the immediate assessment and documentation of the pulse rhythm.

2. During a staff meeting, a nurse is discussing the purpose of regulatory agencies. Which of the following tasks should the nurse identify as the responsibility of state licensing boards?

• A. Monitoring evidence-based practice for clients with specific diagnoses.
• B. Ensuring that health care providers comply with regulations.
• C. Setting quality standards for accrediting health care facilities.
• D. Determining the safety of medications for administration to clients.

Correct answer: B

Rationale: State licensing boards are primarily responsible for ensuring that health care providers comply with regulations. This includes overseeing licensure requirements, investigating complaints, and enforcing disciplinary actions. Monitoring evidence-based practice for clients with specific diagnoses is typically within the domain of professional organizations or healthcare institutions. Setting quality standards for accrediting health care facilities is usually the role of accrediting bodies such as The Joint Commission. Lastly, determining the safety of medications for administration to clients falls under the purview of regulatory agencies like the Food and Drug Administration (FDA).

3. The nurse is assessing a client who has just been admitted with a diagnosis of acute pancreatitis. Which finding is most important for the LPN/LVN to report to the healthcare provider immediately?

• A. Elevated serum lipase level
• B. Severe abdominal pain
• C. Nausea and vomiting
• D. Hypotension

Correct answer: D

Rationale: Hypotension is a critical finding that should be reported immediately in a client with acute pancreatitis as it may indicate severe complications such as hemorrhage or shock. While elevated serum lipase level, severe abdominal pain, and nausea/vomiting are common manifestations of acute pancreatitis, hypotension is a more urgent sign requiring immediate attention to prevent further deterioration. Hypotension can be a sign of significant fluid loss, hemorrhage, or sepsis, which are potentially life-threatening conditions that need prompt intervention. Elevated serum lipase levels, severe abdominal pain, and nausea/vomiting are important in the assessment of pancreatitis but do not indicate the same level of immediate danger as hypotension does.

4. A client with a history of deep vein thrombosis (DVT) is admitted with swelling and pain in the left leg. What is the most appropriate action for the LPN/LVN to take?

• A. Apply warm compresses to the affected leg.
• B. Elevate the left leg above the level of the heart.
• C. Measure the circumference of the left leg.
• D. Administer pain medication as prescribed.

Correct answer: C

Rationale: Measuring the circumference of the left leg is the most appropriate action for an LPN/LVN when assessing a client with a history of DVT and presenting with swelling and pain in the left leg. This measurement helps to assess the extent of swelling objectively and monitor changes in the client's condition. Applying warm compresses (Choice A) may worsen the condition by potentially promoting clot development. Elevating the left leg above the level of the heart (Choice B) is generally recommended for DVT to improve venous return, but measuring the circumference is more appropriate in this scenario. Administering pain medication (Choice D) does not address the underlying issue and should not be the initial action taken.

5. During an assessment, a client receiving tube feedings via NG tube shows signs of nasal mucosa irritation. What finding should the nurse report to the provider?

• A. Potassium 5.5 mEq/L
• B. Irritation of nasal mucosa
• C. Sodium 144 mEq/L
• D. Loose stools

Correct answer: B

Rationale: Irritation of nasal mucosa is a crucial finding that the nurse should report to the provider as it suggests potential complications with NG tube placement, such as improper positioning or mucosal damage. High potassium levels (Choice A) can be concerning but are not directly related to NG tube placement issues. Normal sodium levels (Choice C) and loose stools (Choice D) are common occurrences in clients receiving tube feedings and are not typically indicative of immediate complications that require urgent reporting.

Similar Questions