Nursing Elites

1. A client is admitted with a diagnosis of fluid volume deficit. Which clinical finding would the nurse expect?

• A. Bounding pulse
• B. Bradycardia
• C. Oliguria
• D. Dry mucous membranes

Correct answer: D

Rationale: Dry mucous membranes (D) are a common clinical finding indicating fluid volume deficit. In dehydration, there is insufficient fluid in the body, leading to dry mucous membranes due to decreased saliva production. Bounding pulse (A) is associated with fluid volume excess, not deficit. Bradycardia (B) and oliguria (C) are not typical clinical findings of fluid volume deficit but may be seen in fluid volume excess or other conditions.

2. Following a craniotomy, why did the nurse position the client in low Fowler's position?

• A. To promote comfort.
• B. To promote drainage from the operation site.
• C. To promote thoracic expansion.
• D. To prevent circulatory overload.

Correct answer: B

Rationale: Positioning the client in low Fowler's position after a craniotomy is essential to promote drainage from the operation site. This position helps prevent fluid accumulation, facilitates the removal of excess fluid or blood, and aids in the healing process. Choice A is incorrect because comfort, while important, is not the primary reason for this specific positioning. Choice C is incorrect as thoracic expansion is not the main concern following a craniotomy. Choice D is incorrect as circulatory overload is not typically addressed by positioning in low Fowler's position post-craniotomy.

3. A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?

• A. The client's respiratory rate is 14 breaths per minute.
• B. The client's oxygen saturation is 92%.
• C. The client reports shortness of breath.
• D. The client's respiratory rate is 24 breaths per minute.

Correct answer: C

Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A) is within an acceptable range for a client with COPD and does not require immediate action. An oxygen saturation of 92% (B) is slightly lower but still acceptable in COPD patients. Although a respiratory rate of 24 (D) is higher, it is not as immediately concerning as shortness of breath in this context.

4. One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, 'I think I will plan a big party for all my friends.' How should the nurse respond?

• A. You may not have enough energy before long to hold a big party.
• B. Do you mean to say that you want to plan your funeral and wake?
• C. Planning a party and thinking about all your friends sounds like fun.
• D. You should be thinking about spending your last days with your family.

Correct answer: C

Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse. Choice A is discouraging and focuses on limitations. Choice B jumps to a conclusion and is not in line with the client's statement. Choice D dictates what the client should be doing, which is not respectful of the client's autonomy. Therefore, the most appropriate response is C, as it acknowledges the client's wishes and provides positive reinforcement without perpetuating denial.

5. A client is admitted to the hospital with a diagnosis of pneumonia. Which laboratory test result should the nurse monitor to evaluate the client’s respiratory function?

• A. Arterial blood gases (ABGs)
• B. Complete blood count (CBC)
• C. Blood glucose levels
• D. Serum electrolyte levels

Correct answer: A

Rationale: Arterial blood gases (ABGs) are the most appropriate laboratory test to monitor respiratory function in a client with pneumonia. ABGs provide valuable information on oxygenation status, acid-base balance, and how well the lungs are exchanging gases. This information helps in assessing the effectiveness of ventilation and oxygenation, guiding treatment decisions, and evaluating the overall respiratory status of the client.

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