Nursing Elites

1. A nurse in a mental health facility receives a change of shift report on four clients. Which of the following clients should the nurse plan to assess first?

• A. Client placed in restraints due to aggressive behavior
• B. A new client with a history of 4.5 kg weight loss in the past two months
• C. Client receiving PRN dose of haloperidol 2 hours ago for anxiety
• D. Client receiving first ECT treatment today

Correct answer: A

Rationale: The nurse should plan to assess the client placed in restraints due to aggressive behavior first. Clients in restraints require immediate attention and frequent monitoring for safety. While weight loss, medication administration, and ECT treatment are important, the client in restraints is in a critical situation that requires immediate assessment and intervention.

2. A nurse is providing teaching to a client who is at 36 weeks of gestation and is scheduled for a nonstress test. Which of the following instructions should the nurse include?

• A. The test will last about 30 minutes.
• B. You should drink a full glass of water prior to the test.
• C. You will need to have your bladder full for this test.
• D. This test measures how well your baby's heart responds to movement.

Correct answer: D

Rationale: The correct answer is D. A nonstress test measures the fetal heart's response to movement, helping to assess fetal well-being. Choice A is incorrect as the duration of the test can vary, and it is not always precisely 30 minutes. Choice B is incorrect as drinking water is not necessary for a nonstress test. Choice C is incorrect as having a full bladder is not required for this test.

3. A nurse is caring for a client who has chronic kidney disease and is experiencing fluid volume overload. Which of the following findings should the nurse expect?

• A. Decreased blood pressure
• B. Increased urine output
• C. Decreased heart rate
• D. Increased heart rate

Correct answer: A

Rationale: In a client with chronic kidney disease experiencing fluid volume overload, the nurse should expect a decreased blood pressure. Fluid volume overload can lead to poor cardiac output, which in turn can cause a decrease in blood pressure. Choices B, C, and D are incorrect. Increased urine output is not expected in fluid volume overload; decreased heart rate is not typically associated with fluid volume overload; and an increased heart rate is more commonly seen in response to fluid overload to compensate for the decreased cardiac output.

4. What is the appropriate nursing intervention for a patient with suspected deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Encourage ambulation
• C. Apply compression stockings
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct answer is to administer anticoagulants. Anticoagulants help prevent further clot formation in patients with suspected DVT. Encouraging ambulation can be beneficial in preventing DVT but is not the immediate intervention for a suspected case. Compression stockings are more for DVT prevention rather than treatment. Monitoring oxygen saturation is important in assessing respiratory function but is not the primary intervention for suspected DVT.

5. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?

• A. Place the client in a negative pressure room.
• B. Wear a surgical mask when entering the client's room.
• C. Place the client in droplet isolation.
• D. Place a surgical mask on the client when transporting them.

Correct answer: A

Rationale: The correct answer is to place the client in a negative pressure room. This action is necessary to prevent the spread of tuberculosis, as it is transmitted via airborne particles. Placing the client in droplet isolation (choice C) is not sufficient for tuberculosis, as it requires airborne precautions. Wearing a surgical mask (choice B) when entering the client's room may not provide adequate protection against airborne transmission. Placing a surgical mask on the client when transporting them (choice D) does not address the need for environmental controls to contain infectious particles.

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