Nursing Elites

1. A client is admitted with severe dehydration. What is the most important assessment finding for the nurse to monitor?

• A. Changes in mental status
• B. Urine output and color
• C. Blood pressure and heart rate
• D. Skin turgor

Correct answer: A

Rationale: Changes in mental status are crucial to monitor in a client with severe dehydration. Altered mental status, such as confusion or lethargy, can indicate severe dehydration and potential complications like electrolyte imbalances affecting the brain. Monitoring urine output and color (choice B) is essential but may not provide immediate signs of severe dehydration. While monitoring blood pressure and heart rate (choice C) is important, changes in mental status take precedence as they can indicate more critical conditions. Skin turgor (choice D) is a valuable assessment for dehydration, but changes in mental status take priority due to their direct correlation with severe dehydration.

2. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

• A. Verbalizes a fear of being in a confined space.
• B. Drank a glass of water in the past 2 hours.
• C. Reports left chest wall pain prior to admission.
• D. Experiences facial swelling after eating crab

Correct answer: C

Rationale: The correct answer is C. Left chest wall pain could indicate ongoing cardiac issues or instability, which needs to be assessed before proceeding with the procedure. This pain could be related to the heart and may suggest a potential risk during the angioplasty. Options A, B, and D do not directly relate to cardiac complications during the procedure, making them less urgent for immediate assessment. Fear of confined spaces, drinking water, and facial swelling after eating crab are not immediate risks to the client's safety in the context of a cardiac catheterization procedure.

3. The client who had a below-the-knee (BKA) amputation is being prepared for discharge to home. Which recommendation should the nurse provide this client?

• A. Inspect skin for redness
• B. Use a residual limb shrinker
• C. Apply alcohol to the stump after bathing
• D. Wash the stump with soap and water

Correct answer: D

Rationale: The correct recommendation for a client with a below-the-knee amputation preparing for discharge is to wash the stump with soap and water. This helps maintain cleanliness and prevent infection. Inspecting the skin for redness is important to monitor for signs of infection, but it is not a specific recommendation for a BKA amputation. Using a residual limb shrinker can aid in shaping and reducing swelling in the residual limb but is not usually done immediately after a BKA amputation. Applying alcohol to the stump after bathing is not recommended as it can lead to skin irritation and dryness.

4. In Duchenne muscular dystrophy, if a child has a Gower sign, what behavior should the nurse expect the child to exhibit?

• A. Stands from sitting on the floor by using hands to walk up legs
• B. Exhibits muscular atrophy of upper and lower extremities
• C. Is unable to stand because of contractures of both hips
• D. Walks with an unsteady gait and slaps feet on the floor

Correct answer: A

Rationale: The Gower sign is a characteristic finding in Duchenne muscular dystrophy where a child uses hands to walk up the legs when standing from a sitting position due to proximal muscle weakness. This behavior is indicative of the child trying to compensate for weak hip and thigh muscles. Choices B, C, and D are incorrect because they do not describe the specific behavior associated with the Gower sign. Muscular atrophy, contractures of both hips, and an unsteady gait with foot slapping are not directly related to the Gower sign.

5. An adult client with a broken femur is transferred to the medical-surgical unit to await surgical internal fixation after the application of an external traction device to stabilize the leg. An hour after an opioid analgesic was administered, the client reports muscle spasms and pain at the fracture site. While waiting for the client to be transported to surgery, which action should the nurse implement?

• A. Observe for signs of deep vein thrombosis.
• B. Administer a PRN dose of a muscle relaxant.
• C. Check the client’s most recent electrolyte values.
• D. Reduce the weight on the traction device.

Correct answer: B

Rationale: The correct answer is B: Administer a PRN dose of a muscle relaxant. Muscle spasms and pain might be relieved by muscle relaxants, which are appropriate before surgery. Choice A is incorrect because the client is experiencing muscle spasms, not signs of deep vein thrombosis. Choice C is not the most immediate action needed in this situation. Choice D is incorrect because reducing the weight on the traction device would not directly address the muscle spasms and pain reported by the client.

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