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1. A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?
- A. Hypotension
- B. Distended neck veins
- C. Slow capillary refill
- D. Weak, thready pulse
Correct answer: B
Rationale: The correct answer is B: 'Distended neck veins.' Distended neck veins are a sign of fluid volume excess, indicating an overload of fluids in the body. This can be caused by excessive fluid administration. Hypotension (choice A) is more commonly associated with fluid volume deficit. Slow capillary refill (choice C) and a weak, thready pulse (choice D) are also signs of decreased fluid volume, not fluid volume excess.
2. Which of the following is a potential benefit of social media?
- A. Sharing the fun side of nursing by posting a video of nurses singing and dancing in the hallways of the hospital while on duty
- B. Connecting with clients to keep up with their health status
- C. Connecting with the public to encourage healthy behaviors
- D. Sharing pictures of interesting clinical experiences with friends
Correct answer: C
Rationale: The correct answer is C because connecting with the public to encourage healthy behaviors is a significant benefit of social media. It allows for the dissemination of valuable health information, promoting healthy habits, and raising awareness about important health issues. Choices A, B, and D are not as impactful as choice C in terms of promoting public health and healthy behaviors. Choice A focuses more on entertainment rather than health promotion, choice B is specific to client connections rather than public health initiatives, and choice D is more about sharing experiences rather than encouraging healthy behaviors.
3. The nurse is assessing a 22-year-old patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask?
- A. "Are you anorexic?"
- B. "Is your urine dark colored?"
- C. "Have you lost weight lately?"
- D. "Do you crave sugary drinks?"
Correct answer: C
Rationale: Weight loss is a common symptom in the onset of type 1 diabetes due to the body's inability to use glucose for energy. The lack of insulin leads the body to break down fat and muscle for fuel, causing unintentional weight loss. This is a more relevant question compared to the others, as it directly relates to the metabolic changes associated with type 1 diabetes.
4. A client with limited mobility in their lower extremities is at risk for skin breakdown. Which of the following actions should the nurse take to prevent skin breakdown?
- A. Place the client in high-Fowler's position.
- B. Increase the client's intake of carbohydrates.
- C. Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion.
- D. Have the client use a trapeze bar when changing position
Correct answer: B
Rationale: The correct answer is B: Increase the client's intake of carbohydrates. Adequate nutrition, including carbohydrates, is essential for tissue repair and preventing skin breakdown. Placing the client in high-Fowler's position (choice A) may help with respiratory function but does not directly prevent skin breakdown. Massaging areas of darker skin (choice C) can cause further damage to the skin. Using a trapeze bar (choice D) may assist with changing positions but does not directly address skin breakdown prevention.
5. What is the term for working on a schedule within the unit, involving only those who are working within that unit?
- A. Flexible staffing
- B. Self-staffing
- C. Internal pools
- D. Management scheduling
Correct answer: B
Rationale: The correct answer is B, self-staffing. Self-staffing is the model where staff entirely manage staffing and scheduling themselves, without external involvement. Choices A, C, and D are incorrect. Flexible staffing refers to adjusting staffing levels based on demand. Internal pools involve a group of staff who can be drawn upon for scheduling needs. Management scheduling typically involves supervisors or managers creating and managing schedules for the unit.
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