Nursing Elites

1. When does the nurse act as a client advocate?

• A. Pulling the curtain around the client's bed while changing a dressing
• B. Contacting the health care provider to request a meeting for the client
• C. Ensuring access to medical information by appropriate personnel only
• D. All of the above

Correct answer: D

Rationale: The correct answer is D, 'All of the above.' Acting as a client advocate involves various actions to protect the client's rights and well-being. Pulling the curtain around the client's bed while changing a dressing ensures privacy and dignity. Contacting the health care provider to request a meeting for the client facilitates communication and addresses the client's needs. Ensuring access to medical information by appropriate personnel only safeguards the client's confidentiality and privacy. Therefore, all the actions mentioned in choices A, B, and C are examples of a nurse acting as a client advocate, making D the correct answer.

2. The nurse is caring for a client diagnosed with rule-out nephritic syndrome. Which intervention should be included in the plan of care?

• A. Monitor the urine for bright-red bleeding
• B. Evaluate the calorie count of the 500-mg protein diet
• C. Assess the client’s sacrum for dependent edema
• D. Monitor for a high serum albumin level

Correct answer: C

Rationale: The correct intervention to include in the plan of care for a client with rule-out nephritic syndrome is to assess the client’s sacrum for dependent edema. Dependent edema is common in nephritic syndrome due to protein loss, and monitoring for this helps manage the condition. Choices A, B, and D are incorrect. Monitoring the urine for bright-red bleeding may be more relevant for a client with a different condition, such as glomerulonephritis. Evaluating the calorie count of a 500-mg protein diet is not directly related to managing nephritic syndrome. Monitoring for a high serum albumin level does not directly address the symptom of dependent edema associated with nephritic syndrome.

3. When does short-bowel syndrome usually occur?

• A. The longitudinal muscles of the intestine contract
• B. More than 50% of the small intestine is surgically removed
• C. More than 50% of the large intestine is surgically removed
• D. Transit time is decreased due to infection or drugs

Correct answer: B

Rationale: Short-bowel syndrome typically occurs when more than 50% of the small intestine is surgically removed. This condition leads to malabsorption issues due to the reduced length of the intestine for absorption. Choices A, C, and D are incorrect because short-bowel syndrome specifically relates to the insufficient length of the small intestine, not the contraction of longitudinal muscles, surgical removal of the large intestine, or decreased transit time due to infection or drugs.

4. Which signs/symptoms would the nurse expect to find in the client diagnosed with an insulinoma?

• A. Nervousness, jitteriness, and diaphoresis
• B. Flushed skin, dry mouth, and tented skin turgor
• C. Polyuria, polydipsia, polyphagia
• D. Hypertension, tachycardia, and feeling hot

Correct answer: A

Rationale: Corrected Rationale: Insulinomas lead to excessive insulin production, causing hypoglycemia. Symptoms of hypoglycemia include nervousness, jitteriness, and diaphoresis. These symptoms result from the low blood sugar levels. Flushed skin, dry mouth, and tented skin turgor (choice B) are more indicative of dehydration. Polyuria, polydipsia, and polyphagia (choice C) are classic symptoms of diabetes mellitus, not insulinomas. Hypertension, tachycardia, and feeling hot (choice D) are not typical symptoms of insulinomas.

5. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?

• A. The assistant is putting the stockings on while the client is in the chair
• B. The assistant inserted two (2) fingers under the proximal end of the stocking
• C. The assistant elevated the feet while lying down to put on the stockings
• D. The assistant made sure the toes were warm after putting the stockings on

Correct answer: A

Rationale: The correct answer is A. Compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is incorrect as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C is incorrect as elevating the feet while lying down is a correct technique for applying compression stockings. Choice D is incorrect as ensuring the toes are warm after putting the stockings on is a good practice for client comfort.

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