Nursing Elites

1. While assessing a client with fluid volume deficit, which of the following findings should the nurse expect?

• A. Bradycardia
• B. Increased skin turgor
• C. Dry mucous membranes
• D. Hypertension

Correct answer: C

Rationale: Dry mucous membranes are a classic clinical manifestation of fluid volume deficit. Dehydration leads to reduced fluid intake or excessive fluid loss, resulting in decreased moisture in the mucous membranes. Bradycardia, increased skin turgor, and hypertension are not typically associated with fluid volume deficit. Bradycardia is more commonly seen in conditions like hypothyroidism or increased intracranial pressure. Increased skin turgor is a sign of dehydration, not deficit. Hypertension is not a typical finding in fluid volume deficit.

2. When planning to perform a sterile dressing change for a client, which of the following actions should a healthcare professional take?

• A. Wear sterile gloves to remove the old dressing.
• B. Cleanse the wound with an antiseptic solution.
• C. Use clean gloves to apply the new dressing.
• D. Open sterile supplies before donning sterile gloves.

Correct answer: D

Rationale: Opening sterile supplies before donning sterile gloves is a critical step in maintaining the sterility of the supplies during a dressing change procedure. By doing so, the healthcare professional ensures that they do not touch non-sterile surfaces with their hands once sterile gloves are worn, reducing the risk of introducing pathogens to the wound and minimizing the potential for contamination.

3. A client with a new prescription for a dry-powder inhaler (DPI) is receiving teaching from a healthcare provider. Which of the following statements indicates an understanding of the teaching?

• A. I will shake the inhaler before use.
• B. I will take the medication with food.
• C. I will inhale the medication quickly.
• D. I will use a spacer with the inhaler.

Correct answer: C

Rationale: Choosing option C, 'I will inhale the medication quickly,' demonstrates an understanding of DPI use. Inhaling the medication quickly ensures effective delivery of the dry powder to the lungs, maximizing its therapeutic effects. Options A, B, and D are incorrect as shaking the DPI, taking it with food, and using a spacer are not recommended practices for DPI administration. Shaking a DPI can cause clumping or uneven dispersion of the medication, taking it with food may not affect its efficacy but can increase the risk of side effects, and using a spacer is not necessary for DPIs which are breath-actuated and do not require coordination with inhalation through a spacer.

4. A client with dysphagia and at risk for aspiration needs care planning. Which intervention should the nurse include in the plan?

• A. Encourage the client to drink thickened liquids.
• B. Instruct the client to swallow with chin tucked.
• C. Provide the client with a cup with a lid.
• D. Place the client in Fowler's position for meals.

Correct answer: D

Rationale: Placing the client in Fowler's position is crucial in preventing aspiration as it helps maintain an open airway and reduces the risk of food or liquid entering the lungs during swallowing. This position promotes safer swallowing and minimizes the chances of aspiration pneumonia. Choices A, B, and C are less effective interventions for preventing aspiration. Encouraging the client to drink thickened liquids may help, but the position is more critical. Instructing the client to swallow with chin tucked is beneficial for some individuals but not as effective as positioning. Providing a cup with a lid does not directly address the risk of aspiration associated with dysphagia.

5. A healthcare provider is caring for a client who is receiving IV therapy via a peripheral catheter. The healthcare provider should identify that which of the following findings is an indication of infiltration?

• A. Redness at the infusion site
• B. Edema at the infusion site
• C. Warmth at the infusion site
• D. Oozing of blood at the infusion site

Correct answer: B

Rationale: Edema at the infusion site is an indication of infiltration, where fluid leaks into the surrounding tissues causing swelling. This can compromise the delivery of medication and fluids, potentially leading to complications. Redness, warmth, and oozing of blood are more suggestive of inflammation or infection rather than infiltration. Infiltration requires prompt recognition and intervention to prevent further issues with the IV therapy.

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