Nursing Elites

1. A nurse is caring for a client who has mild anxiety. Which of the following findings should the nurse expect?

• A. Feelings of dread
• B. Rapid speech
• C. Purposeless activity
• D. Heightened perceptual field

Correct answer: D

Rationale: In mild anxiety, the client is expected to have a heightened perceptual field. This means that their perception is increased, enhancing their awareness and ability to concentrate. Feelings of dread (Choice A) are more common in moderate to severe anxiety. Rapid speech (Choice B) and purposeless activity (Choice C) are more indicative of moderate to severe anxiety where the individual may exhibit signs of agitation and restlessness.

2. A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?

• A. Feeling flushed and warm
• B. Abdominal fullness
• C. Swollen lips
• D. Metallic taste in the mouth

Correct answer: C

Rationale: Swollen lips indicate a potential allergic reaction or anaphylaxis to the contrast dye used during the procedure, which requires immediate medical intervention. Abdominal fullness and metallic taste are common side effects of IV urography and can be managed without urgent intervention. Feeling flushed and warm may also be a common reaction during the procedure and does not indicate a life-threatening situation like an allergic reaction.

3. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate via IV infusion. Which of the following findings indicates magnesium toxicity?

• A. Blood glucose of 150 mg/dL
• B. Urine output of 20 mL/hour
• C. Systolic blood pressure of 140 mm Hg
• D. BUN 20 mg/dL

Correct answer: B

Rationale: The correct answer is B. A urine output of 20 mL/hour is a sign of magnesium toxicity because decreased urine output can lead to accumulation of magnesium. Choices A, C, and D are not indicators of magnesium toxicity. Elevated blood glucose, high systolic blood pressure, and normal BUN levels do not specifically point towards magnesium toxicity.

4. A nurse is teaching about measures to promote sleep for a client with insomnia. What statement indicates understanding?

• A. I should reduce my fluid intake to 2 hours before bedtime
• B. I will watch TV in bed before sleeping
• C. I can take long naps during the day
• D. I should exercise right before going to bed

Correct answer: A

Rationale: The correct answer is A. Reducing fluid intake to 2-4 hours before sleeping helps prevent interruptions during the night, promoting better sleep. Watching TV in bed before sleeping (choice B) can actually hinder sleep due to the stimulation from screens. Taking long naps during the day (choice C) can disrupt the natural sleep-wake cycle. Exercising right before going to bed (choice D) can increase alertness and make it harder to fall asleep.

5. A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

• A. Apply skin preparation to wound edges
• B. Cleanse the wound with normal saline
• C. Don sterile gloves
• D. Determine the client's pain level

Correct answer: D

Rationale: The correct answer is to determine the client's pain level first. Assessing the client's pain is crucial before proceeding with any procedure, including dressing changes. This step ensures that appropriate pain management measures can be implemented, making the wound care process as comfortable as possible for the patient. Applying skin preparation to wound edges (choice A) can come after addressing the pain. While cleansing the wound with normal saline (choice B) and donning sterile gloves (choice C) are important steps in wound care, they should follow the assessment of the client's pain level to prioritize the patient's comfort and well-being.

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