Nursing Elites

1. A client has had vomiting and diarrhea for the past 3 days. Which of the following findings indicates the client is experiencing fluid volume deficit?

• A. Jugular vein distention
• B. Bradycardia
• C. Increased respiratory rate
• D. Bounding pulses

Correct answer: C

Rationale: An increased respiratory rate is a sign of fluid volume deficit as the body attempts to compensate for decreased blood volume. Jugular vein distention, bradycardia, and bounding pulses are not typical findings of fluid volume deficit. Jugular vein distention is more commonly associated with fluid volume overload, bradycardia can be a sign of fluid volume excess or other issues, and bounding pulses are not typically seen in fluid volume deficit.

2. A nurse is planning care for a client who had gastric bypass surgery 1 week ago and has signs of early dumping syndrome. Which of the following findings should the nurse expect?

• A. Facial flushing
• B. Syncope
• C. Diaphoresis
• D. Bradycardia

Correct answer: A

Rationale: Facial flushing is a common symptom of early dumping syndrome, which occurs when food moves too quickly into the small intestine. This rapid movement triggers the release of vasoactive peptides causing vasodilation, leading to facial flushing. Syncope (choice B) is not a typical finding in early dumping syndrome. Diaphoresis (choice C) and bradycardia (choice D) are also not characteristic symptoms of early dumping syndrome.

3. A nurse is assessing a client who has a history of angina and reports chest pain. Which of the following actions should the nurse take first?

• A. Administer oxygen at 2 L/min via nasal cannula.
• B. Obtain a 12-lead ECG.
• C. Administer nitroglycerin sublingually.
• D. Notify the provider.

Correct answer: B

Rationale: The correct answer is to obtain a 12-lead ECG. In a client with a history of angina and reporting chest pain, the priority action is to assess for myocardial infarction, which is best done through an ECG. Administering oxygen, nitroglycerin, or notifying the provider can be important actions but obtaining an ECG takes precedence in evaluating the client's condition.

4. A nurse is reviewing the medical record of a client who has major depressive disorder and is taking tranylcypromine. Which of the following foods should the nurse instruct the client to avoid?

• A. Milk
• B. Bananas
• C. Yogurt
• D. Cured meats

Correct answer: D

Rationale: The correct answer is D: Cured meats. Cured meats contain tyramine, which can lead to a hypertensive crisis in clients taking tranylcypromine. Bananas, milk, and yogurt do not contain significant amounts of tyramine and are safe for clients taking this medication. Therefore, the nurse should instruct the client to avoid cured meats to prevent adverse effects.

5. What is the most effective intervention for a patient experiencing acute pain?

• A. Administer analgesics
• B. Reposition the patient
• C. Provide non-pharmacological interventions
• D. Administer IV fluids

Correct answer: A

Rationale: Administering analgesics is the most effective intervention for a patient experiencing acute pain as it directly targets the pain receptors and provides relief. Repositioning the patient may help in some cases, but it is not the primary intervention for managing acute pain. Non-pharmacological interventions can be beneficial as adjuncts to pain management but might not provide immediate relief. Administering IV fluids is not a standard intervention for acute pain unless dehydration is contributing to the pain.

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