Nursing Elites

1. A client in the emergency department is being cared for by a nurse and has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

• A. Tachycardia
• B. Elevated blood pressure
• C. Warm, dry skin
• D. Decreased respiratory rate

Correct answer: A

Rationale: Tachycardia is a hallmark sign of hypovolemic shock. When a client experiences significant blood loss, the body compensates by increasing the heart rate to maintain adequate perfusion to vital organs. Elevated blood pressure is not typically seen in hypovolemic shock; instead, hypotension is a more common finding. Warm, dry skin is characteristic of neurogenic shock, not hypovolemic shock. Decreased respiratory rate is not a typical manifestation of hypovolemic shock, as the body usually tries to increase respiratory effort to improve oxygenation in response to hypovolemia.

2. What is the rate of delivery in mL/hr if a total volume of 750 mL is infused over a period of 7 hours?

• A. 107 mL/hr.
• B. 107 mL/hr.
• C. 107 mL/hr.
• D. 107 mL/hr.

Correct answer: A

Rationale: The correct rate of delivery is 107 mL/hr. To find the rate of delivery, divide the total volume by the total time: 750 mL / 7 hours = 107 mL/hr. Choice B, C, and D are incorrect as they do not match the correct calculation based on the total volume and time provided.

3. A healthcare professional is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the healthcare professional take next?

• A. Assess the client for orthostatic hypotension
• B. Obtain a gait belt
• C. Ensure the client has proper footwear
• D. Ask the client to perform range-of-motion exercises

Correct answer: A

Rationale: Assessing the client for orthostatic hypotension is the priority before transferring a client who can bear weight on one leg. This assessment helps identify the risk of dizziness or fainting when the client moves from a supine to an upright position. Obtaining a gait belt may be necessary for the transfer, but assessing for orthostatic hypotension comes first to ensure the safety of the client. Ensuring the client has proper footwear is important for preventing falls during ambulation but is not the immediate next step in this situation. Asking the client to perform range-of-motion exercises is not necessary before the transfer and does not address the immediate safety concern of orthostatic hypotension.

4. A healthcare professional is planning care to improve self-feeding for a client with vision loss. Which of the following interventions should the healthcare professional include in the plan of care?

• A. Instruct the client on the sequence of foods to eat first
• B. Offer small-handle utensils for the client to use
• C. Thicken liquids served to the client
• D. Use a clock pattern to indicate food placement on the client's plate

Correct answer: D

Rationale: The correct answer is D. When a client has vision loss, using a clock pattern to describe food placement on the plate can facilitate independent eating. This method enables the client to locate different food items based on their positions, enhancing self-feeding abilities. Instructing the client on the sequence of foods to eat first (Choice A) may not address the visual impairment directly. Providing small-handle utensils (Choice B) can be helpful for clients with limited dexterity but may not specifically assist a client with vision loss. Thickening liquids (Choice C) is more relevant for clients with dysphagia, not vision loss.

5. The nurse is preparing to administer a subcutaneous injection of insulin to a client with diabetes. What is the best site for the nurse to select for this injection?

• A. Ventrogluteal site
• B. Dorsogluteal site
• C. Deltoid site
• D. Abdomen

Correct answer: D

Rationale: The correct answer is 'D: Abdomen.' The abdomen is the best site for insulin injections as it provides a larger area with consistent absorption rates due to the high vascularity of the area. The subcutaneous tissue in the abdomen allows for a more predictable and consistent absorption of insulin compared to other sites. Ventrogluteal and dorsogluteal sites are not commonly used for insulin injections due to the risk of hitting the sciatic nerve or causing tissue damage. The deltoid site is more commonly used for intramuscular injections rather than subcutaneous injections like insulin.

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