Nursing Elites

1. A healthcare provider is assessing a client who has severe dehydration. Which finding indicates effective treatment?

• A. Sunken anterior fontanel
• B. Tenting skin turgor
• C. Flat anterior fontanel
• D. Hyperpnea

Correct answer: C

Rationale: A flat anterior fontanel indicates effective treatment for dehydration in infants. Dehydration often causes sunken fontanels, so when the anterior fontanel becomes flat, it suggests that rehydration has occurred. Sunken anterior fontanel (Choice A) is a sign of dehydration, not effective treatment. Tenting skin turgor (Choice B) is also a sign of dehydration, indicating poor skin turgor. Hyperpnea (Choice D) is increased depth and rate of breathing and is not directly related to the hydration status of the client.

2. A healthcare professional is assessing a client for signs of fluid overload. Which of the following findings should the healthcare professional look for?

• A. Weight loss
• B. Decreased blood pressure
• C. Edema
• D. Increased urine output

Correct answer: C

Rationale: Edema is a common sign of fluid overload. When the body retains more fluid than it excretes, it can lead to edema, which is swelling caused by excess fluid trapped in body tissues. Weight gain, not weight loss, is typically associated with fluid overload due to the retained fluids. Decreased blood pressure is more commonly associated with dehydration rather than fluid overload. Increased urine output is a sign of the body trying to eliminate excess fluids, which is contrary to the signs of fluid overload.

3. A client wearing an arm cast reports numb fingers. Which of the following actions should the nurse take first?

• A. Place the arm in a dependent position
• B. Administer pain medication
• C. Check the client's circulation
• D. Apply a warm compress to the fingers

Correct answer: C

Rationale: The correct answer is to check the client's circulation. Numbness in the fingers may indicate compromised circulation or nerve damage. By assessing the circulation first, the nurse can ensure that the cast is not too tight, which could be cutting off blood flow. Option A is incorrect because placing the arm in a dependent position may worsen circulation issues. Option B is incorrect as administering pain medication does not address the underlying cause of numbness. Option D is incorrect as applying a warm compress could mask circulation issues and is not the priority in this situation.

4. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which of the following types of immunity?

• A. Innate immunity
• B. Passive immunity
• C. Acquired immunity
• D. Natural immunity

Correct answer: C

Rationale: Immunizations provide acquired immunity. They work by introducing antigens into the body, which triggers the immune system to produce antibodies specific to that antigen. Choice A, 'Innate immunity,' refers to the natural defense mechanisms an organism is born with and does not involve immunizations. Choice B, 'Passive immunity,' is the transfer of pre-formed antibodies and does not involve immunizations. Choice D, 'Natural immunity,' is a general term that encompasses all immunity that is not acquired through deliberate immunization or passive transfer of antibodies.

5. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?

• A. Perform palpation before auscultation
• B. Perform percussion before auscultation
• C. Perform palpation after auscultation
• D. Perform inspection after auscultation

Correct answer: C

Rationale: The correct answer is C: Perform palpation after auscultation. When conducting an abdominal assessment, the correct sequence is inspection, auscultation, percussion, and then palpation. Inspecting the abdomen allows the nurse to observe any visible abnormalities, followed by listening for bowel sounds during auscultation. Percussion helps assess the density of abdominal contents before palpation for tenderness, masses, or organ enlargement. Choices A, B, and D are incorrect because palpation should always come last in the sequence of an abdominal assessment.

Similar Questions