Nursing Elites

1. A client is being treated for dehydration. Which clinical finding would indicate that treatment is effective?

• A. Dry mucous membranes
• B. Increased urine output
• C. Tachycardia
• D. Hypotension

Correct answer: B

Rationale: The correct answer is B: Increased urine output. When a client is being treated for dehydration, increased urine output is a positive indication that the treatment is effective. This signifies that the body is beginning to rehydrate and eliminate excess fluid. Choices A, C, and D are incorrect because dry mucous membranes, tachycardia, and hypotension are all associated with dehydration and would not be signs of effective treatment.

2. The nurse is caring for a client who has just returned from surgery with a urinary catheter in place. What is the most important action to prevent catheter-associated urinary tract infections (CAUTIs)?

• A. Irrigate the catheter daily
• B. Ensure the catheter bag is always below bladder level
• C. Change the catheter every 48 hours
• D. Administer prophylactic antibiotics

Correct answer: B

Rationale: The correct answer is to ensure the catheter bag is always below bladder level. This positioning helps prevent backflow of urine, reducing the risk of CAUTIs. Choice A, irrigating the catheter daily, is not recommended as it can introduce pathogens into the bladder. Changing the catheter too frequently (Choice C) can increase the risk of introducing pathogens. Administering prophylactic antibiotics (Choice D) is not the primary intervention for preventing CAUTIs and can lead to antibiotic resistance.

3. The nurse notes that a postoperative client's wound site is red and slightly swollen. What is the most appropriate action?

• A. Apply an ice pack
• B. Document the findings and monitor
• C. Notify the surgeon
• D. Clean the wound with sterile saline

Correct answer: C

Rationale: The correct answer is to notify the surgeon. Redness and swelling at a wound site can indicate an infection, which may require medical intervention. Applying an ice pack (choice A) is not appropriate without further assessment. While documenting the findings and monitoring (choice B) is important, it should be accompanied by notifying the surgeon for further evaluation. Cleaning the wound with sterile saline (choice D) may not be sufficient if an infection is present, so immediate communication with the surgeon is crucial.

4. The nurse is assessing a client with a suspected pulmonary embolism (PE). Which symptom is most indicative of this condition?

• A. Bilateral leg swelling.
• B. Sudden onset of chest pain.
• C. Gradual onset of dyspnea.
• D. Decreased breath sounds on auscultation.

Correct answer: C

Rationale: The correct answer is C: 'Gradual onset of dyspnea.' While pulmonary embolism can present with various symptoms, the most common include sudden onset of dyspnea, chest pain (often pleuritic in nature), tachypnea, and tachycardia. Bilateral leg swelling is more commonly associated with conditions like deep vein thrombosis, not pulmonary embolism. Decreased breath sounds on auscultation may be seen in conditions like pneumothorax, not typically in pulmonary embolism. Therefore, the gradual onset of dyspnea is the most indicative symptom of pulmonary embolism in this scenario.

5. A healthcare provider is reviewing a client's medication list during a routine visit. Which action is most important to ensure medication safety?

• A. Ask the client about any allergies to medications
• B. Review the purposes of each medication
• C. Check for potential drug interactions
• D. All of the above

Correct answer: D

Rationale: A comprehensive review of allergies, medication purposes, and potential interactions is crucial for ensuring medication safety. Asking about allergies helps prevent adverse reactions, reviewing medication purposes ensures the correct use of each drug, and checking for potential drug interactions reduces the risk of harmful effects when medications interact. Choosing 'All of the above' is the correct answer because all three actions are essential steps to enhance medication safety. Options A, B, and C individually play vital roles in promoting medication safety, making option D the most appropriate choice.

Similar Questions