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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. A client is discussing the use of herbal supplements for health promotion with a nurse. Which of the following client statements indicates an understanding of herbal supplement use?
- A. I can take echinacea to improve my immune system.
- B. I can take feverfew to reduce my level of anxiety.
- C. I can take ginger to improve my memory.
- D. I can take ginkgo biloba to relieve nausea.
Correct answer: D
Rationale: The correct answer is D. Ginkgo biloba is commonly used to improve blood circulation and relieve symptoms of cognitive disorders like dementia. The other choices are incorrect because echinacea is used to boost the immune system, feverfew is used for migraines and headaches, and ginger is known for its anti-inflammatory properties and aiding digestion, not memory improvement.
3. A __________ is often helpful to use when a problem is not easily identified.
- A. trial and error
- B. Delphi method
- C. political decision-making model
- D. affinity map
Correct answer: D
Rationale: An affinity map is a tool commonly used when a problem is not easily identified. It helps in organizing and grouping ideas, data, or information based on relationships or themes. Choice A, 'trial and error,' involves repeatedly trying different solutions until the problem is solved, which may not be efficient when the problem is not clearly defined. Choice B, the 'Delphi method,' is a structured communication technique for experts to reach a consensus, not specifically for unidentified problems. Choice C, 'political decision-making model,' refers to a process for making decisions in political contexts and is not directly related to identifying unknown problems.
4. What is the primary role of a nurse in an interdisciplinary team?
- A. To lead the healthcare team
- B. To advocate for the patient
- C. To provide emotional support to the patient
- D. To ensure compliance with regulations
Correct answer: B
Rationale: The correct answer is B: 'To advocate for the patient.' Nurses play a crucial role in interdisciplinary teams by ensuring that the patient's needs and preferences are considered in the care plan. While leadership (Choice A) can be a part of a nurse's responsibilities in certain situations, the primary role is patient advocacy. Providing emotional support (Choice C) is important but not the primary role in an interdisciplinary team. Ensuring compliance with regulations (Choice D) is important but not the primary focus when working within an interdisciplinary team.
5. A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?
- A. You should receive a pneumococcal vaccine when you are 65 years old.
- B. You should receive a shingles vaccine when you are 70 years old.
- C. You should receive a tetanus booster every 5 years.
- D. You should have an eye examination every 2 years.
Correct answer: A
Rationale: The correct answer is A. The CDC recommends a pneumococcal vaccine for all adults aged 65 years and older. This vaccine helps protect against serious pneumococcal disease. Choice B is incorrect as the shingles vaccine is recommended for adults aged 50 years and older, not specifically at 70 years. Choice C is incorrect because a tetanus booster is recommended every 10 years, not every 5 years. Choice D is incorrect as the general recommendation for eye examinations in older adults is annually, not every 2 years.
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