Nursing Elites

1. A nurse is assessing a client who is experiencing acute pain. Which of the following manifestations should the nurse expect?

• A. Hypertension
• B. Bradycardia
• C. Diaphoresis
• D. Piloerection

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common manifestation of acute pain caused by increased sympathetic nervous system activity. This response is the body's way of trying to regulate body temperature during the stress response. Choices A, B, and D are incorrect. Hypertension (Choice A) and tachycardia (not bradycardia as in Choice B) are more likely responses to acute pain due to sympathetic nervous system activation. Piloerection (Choice D), also known as goosebumps, is not a typical manifestation of acute pain.

2. A nurse is assessing a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

• A. Increased appetite
• B. Dry mucous membranes
• C. Hypotension
• D. Hyperreflexia

Correct answer: C

Rationale: A sodium level of 125 mEq/L indicates hyponatremia, which can lead to hypotension. Hyponatremia is associated with signs such as confusion and weakness, rather than increased appetite, dry mucous membranes, or hyperreflexia. Therefore, the nurse should expect hypotension as a finding in a client with a sodium level of 125 mEq/L.

3. A client who has a prescription for insulin glargine is talking to a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will mix this insulin with my regular insulin before injecting it.
• B. I will store this insulin in the refrigerator after opening it.
• C. I will take this insulin twice a day.
• D. I will inject this insulin when my blood glucose is above 200 mg/dL.

Correct answer: B

Rationale: The correct answer is B because insulin glargine should be stored in the refrigerator after opening to maintain its potency. Choice A is incorrect as insulin glargine should not be mixed with other insulins. Choice C is incorrect because insulin glargine is typically taken once a day. Choice D is incorrect because insulin glargine is usually taken regardless of blood glucose levels.

4. A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse take first?

• A. Apply a sterile dressing.
• B. Suction the tracheostomy.
• C. Remove the inner cannula.
• D. Clean the stoma with sterile saline.

Correct answer: B

Rationale: Suctioning the tracheostomy should be performed first to clear the airway of secretions and ensure proper oxygenation before proceeding with other care. This helps maintain a patent airway and prevent complications such as aspiration. Applying a sterile dressing, removing the inner cannula, or cleaning the stoma can follow after ensuring adequate airway clearance through suctioning.

5. What is the most important assessment for a patient with suspected pneumonia?

• A. Monitor lung sounds
• B. Check oxygen saturation
• C. Assess for cough
• D. Assess for fever

Correct answer: A

Rationale: The most important assessment for a patient with suspected pneumonia is to monitor lung sounds. Lung sounds provide crucial information about the severity of pneumonia, such as crackles or decreased air entry. This assessment helps in evaluating the effectiveness of ventilation and oxygenation. While checking oxygen saturation is important, monitoring lung sounds gives more direct information about the lung involvement in pneumonia. Assessing for cough and fever are also relevant but do not provide as direct and critical information as monitoring lung sounds in the context of suspected pneumonia.

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