Nursing Elites

1. A nurse in an emergency department is monitoring the hydration status of a client receiving oral rehydration. What finding should the nurse intervene for?

• A. Heart rate of 80 beats per minute
• B. Heart rate of 120 beats per minute
• C. Blood pressure of 110/70 mmHg
• D. Respiratory rate of 16 breaths per minute

Correct answer: B

Rationale: A heart rate of 120 beats per minute indicates tachycardia, which can be a sign of dehydration and requires intervention. A heart rate of 80 beats per minute is within the normal range and does not indicate dehydration. A blood pressure of 110/70 mmHg is considered normal. A respiratory rate of 16 breaths per minute is also within the normal range and does not point towards dehydration.

2. A client signed an informed consent form for surgery but has expressed doubts about the need for surgery. What should the nurse say?

• A. Reassure the client of the surgeon's skill
• B. The surgeon will answer your questions before surgery
• C. Tell the client surgery is necessary
• D. Encourage the client to seek a second opinion

Correct answer: B

Rationale: The correct answer is B because the surgeon should address the client's doubts before surgery. Informed consent requires that the client fully understands the procedure. Choice A is incorrect because reassuring the client of the surgeon's skill does not address the client's doubts about the need for surgery. Choice C is incorrect because telling the client surgery is necessary may not address their concerns and could violate the principle of autonomy. Choice D is incorrect as the immediate concern is addressing the client's doubts before surgery, not necessarily seeking a second opinion.

3. A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. What factor should the nurse identify as contributing to this decrease?

• A. Increased activity level
• B. Bowel inflammation
• C. Long-term use of the medication
• D. History of dehydration

Correct answer: B

Rationale: Bowel inflammation can reduce the absorption of oral medications, leading to decreased effectiveness. In this case, the decrease in the effectiveness of the arthritis medication could be attributed to impaired absorption due to bowel inflammation. Choices A, C, and D are incorrect because increased activity level, long-term use of the medication, and history of dehydration are not directly associated with a decrease in medication effectiveness related to absorption issues.

4. A client with diabetes mellitus is being taught about foot care by a nurse. Which statement indicates understanding?

• A. I will soak my feet in hot water daily
• B. I will wear my slippers whenever I am out of bed
• C. I should apply lotion between my toes after washing my feet
• D. I will cut my nails in a rounded shape

Correct answer: B

Rationale: The correct answer is B. Wearing slippers or shoes when out of bed is crucial for clients with diabetes as it helps prevent injuries to the feet, reducing the risk of infection. Choices A, C, and D are incorrect. Soaking feet in hot water daily can lead to dryness and skin damage, applying lotion between toes can create a moist environment promoting fungal growth, and cutting nails in a rounded shape can increase the risk of ingrown nails.

5. A nurse is reviewing a client's health history and identifies a history of pressure injuries. What intervention should the nurse include in the plan of care?

• A. Reposition the client every 4 hours
• B. Apply a moisture-retentive dressing
• C. Apply a heating pad to the site
• D. Keep the client on bedrest

Correct answer: B

Rationale: The correct intervention for a client with pressure injuries is to apply a moisture-retentive dressing. This type of dressing helps create a moist wound environment, which is conducive to healing. Repositioning the client every 4 hours is important to prevent further pressure injuries, but it is not the primary intervention for existing pressure injuries. Applying a heating pad to the site can increase the risk of tissue damage and is contraindicated for pressure injuries. Keeping the client on bedrest can lead to further complications and delayed healing of pressure injuries.

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