Nursing Elites

1. A healthcare professional is caring for a client who has an arteriovenous fistula. Which of the following findings should the healthcare professional report?

• A. Thrill upon palpation.
• B. Absence of a bruit.
• C. Distended blood vessels.
• D. Swishing sound upon auscultation.

Correct answer: B

Rationale: The correct answer is B: Absence of a bruit. In a client with an arteriovenous fistula, the presence of a bruit (a humming sound) is an expected finding due to the high-pressure flow of blood through the fistula. Therefore, the absence of a bruit suggests a complication, such as thrombosis or stenosis, which should be reported for further evaluation and management. Choices A, C, and D are incorrect because a thrill upon palpation, distended blood vessels, and a swishing sound upon auscultation are expected findings in a client with an arteriovenous fistula and do not necessarily indicate a complication.

2. When documenting an incorrect dose of medication administered, which fact related to the incident report should the nurse document in the client's medical record?

• A. Time the medication was given
• B. The client's response to the medication
• C. The dose that was administered
• D. Reason for the error

Correct answer: A

Rationale: The nurse should document the time the medication was given in the client's medical record when an incorrect dose is administered. Recording the time is crucial for establishing the sequence of events accurately. Choices B, C, and D, though important, are not directly relevant to documenting the incident of administering an incorrect dose of medication. The client's response to the medication, the actual dose administered, and the reason for the error may be documented for overall patient care but are not specifically required in the incident report for an incorrect dose.

3. A client with lactose intolerance and has eliminated dairy products from his diet should increase consumption of which of the following foods?

• A. Spinach
• B. Peanut butter
• C. Ground beef
• D. Carrots

Correct answer: A

Rationale: Spinach is the correct answer because it is a good source of calcium. Since the client has eliminated dairy products due to lactose intolerance, which are a common source of calcium, increasing spinach consumption can help compensate for the lost calcium. Peanut butter, ground beef, and carrots are not significant sources of calcium and therefore not the best choice for this client.

4. A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to assess first?

• A. A client who has a fractured femur and reports feeling short of breath.
• B. A client who is postoperative and has abdominal distention.
• C. A client who is receiving IV fluids and has a temperature of 38.5°C (101.3°F).
• D. A client who has cancer and has been receiving radiation therapy.

Correct answer: A

Rationale: The correct answer is A. A client with a fractured femur and reports feeling short of breath is at risk for a fat embolism, which is a medical emergency. The nurse should assess this client first to rule out this serious complication. Choice B may indicate paralytic ileus, which is important but not immediately life-threatening compared to a fat embolism. Choice C has a fever, which indicates infection but is not as urgent as a potential fat embolism. Choice D, a client receiving radiation therapy, is not experiencing an acute, life-threatening complication that requires immediate assessment compared to a fat embolism.

5. A client expresses fear of surgery. Which response should the nurse make?

• A. Explain the risks of the surgery in detail.
• B. Tell the client that many clients feel anxious before surgery.
• C. Reassure the client that the surgical team is highly experienced.
• D. Acknowledge the client's feelings and ask open-ended questions.

Correct answer: D

Rationale: When a client expresses fear of surgery, it is essential for the nurse to acknowledge their feelings and ask open-ended questions. This response shows empathy, validates the client's emotions, and encourages them to express their concerns further. Explaining the risks of the surgery in detail (Choice A) may increase the client's anxiety. Simply stating that many clients feel anxious before surgery (Choice B) does not address the client's specific fears. While reassuring the client about the surgical team's experience (Choice C) is important, it may not directly alleviate the client's fear.

Similar Questions