Nursing Elites

1. A 25-year-old primigravida at 16 weeks gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. Which nursing diagnosis should have the highest priority?

• A. Fluid volume deficit
• B. Altered nutrition: less than body requirements
• C. Anxiety related to new situational crisis
• D. Activity intolerance related to fatigue

Correct answer: A

Rationale: In a case of hyperemesis gravidarum, the priority nursing diagnosis should be addressing the Fluid volume deficit. This condition can lead to serious complications such as electrolyte imbalances and dehydration, which can endanger both the mother and the fetus if not managed promptly. Altered nutrition: less than body requirements is important but addressing the fluid volume deficit takes precedence as it poses an immediate threat. Anxiety related to new situational crisis and Activity intolerance related to fatigue are valid concerns, but they are secondary to the critical issue of fluid volume deficit in this scenario.

2. After performing foot care, the nurse checks the medical record and discovers that the patient has a disorder on the sole of the foot caused by a virus. Which condition did the nurse most likely observe?

• A. Corns
• B. A callus
• C. Plantar warts
• D. Athlete's foot

Correct answer: C

Rationale: The nurse most likely observed plantar warts, which appear on the sole of the foot and are caused by the papillomavirus. Corns (Choice A) and calluses (Choice B) are areas of thickened skin caused by pressure or friction and are not typically associated with viruses. Athlete's foot (Choice D) is a fungal infection that usually affects the skin between the toes and is not caused by a virus like plantar warts.

3. A client reports mild back pain after receiving analgesia 1 hour ago. Which non-pharmacological pain method should the nurse plan to use?

• A. Apply an ice pack to the client's back for 1 hour.
• B. Remove distractions from the client’s room.
• C. Instruct the client to take deep rhythmic breaths.
• D. Encourage the client to apply a heating pad for 2 hours at a time.

Correct answer: C

Rationale: In this scenario, the nurse should instruct the client to take deep rhythmic breaths as a non-pharmacological pain management method. Deep breathing can help the client relax, reduce stress, and manage pain effectively. Applying heat or ice for prolonged periods can lead to tissue damage. Removing distractions can be helpful for promoting relaxation but may not directly address the pain itself.

4. What should be done when caring for a client who died?

• A. Obtain orders, Remove tubes, Wash client, Ask family, Place tags.
• B. Wash client, Obtain orders, Place tags, Remove tubes, Ask family.
• C. Remove tubes, Obtain orders, Ask family, Place tags, Wash client.
• D. Ask family, Place tags, Wash client, Remove tubes, Obtain orders.

Correct answer: A

Rationale: When caring for a deceased client, the correct sequence of actions involves first obtaining any necessary orders, then removing tubes, washing the client, asking the family for specific requests, and finally placing identification tags. This order ensures proper care and respect for the deceased individual. Option A presents the correct order of actions. Choice B is incorrect because washing the client should be done after removing tubes. Choice C is incorrect as it does not follow the correct order of actions. Choice D is incorrect because asking the family should be done after caring for the client's body, not before.

5. A nurse at an assisted living facility is preparing an in-service for residents about electrical safety. Which of the following instructions should the nurse include?

• A. Avoid taping electrical cords to the floor.
• B. Clean electrical equipment before disconnection.
• C. Cover exposed wires with tape before use.
• D. Disconnect electrical equipment by grasping the plug.

Correct answer: A

Rationale: The correct instruction for electrical safety is to avoid taping electrical cords to the floor. Taping cords can create tripping hazards, leading to falls and potential injuries. Choice B, cleaning electrical equipment before disconnection, is not directly related to electrical safety but rather to equipment maintenance. Choice C, covering exposed wires with tape before use, is incorrect as exposed wires should be properly insulated and repaired by a qualified professional. Choice D, disconnecting electrical equipment by grasping the plug, is unsafe and can lead to electrical shocks. It is always recommended to unplug devices by holding the plug itself, not by pulling the cord.

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