Nursing Elites

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

• A. Decreased level of consciousness
• B. Inability to identify common objects
• C. Preoccupation with somatic disturbances
• D. Poor problem-solving ability

Correct answer: B

Rationale: The correct answer is B: Inability to identify common objects. Clients with schizophrenia often experience cognitive deficits, such as difficulty in identifying common objects. This can be attributed to impairments in perception and cognition. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head injuries or metabolic disturbances. Preoccupation with somatic disturbances is commonly seen in somatic symptom disorders, not schizophrenia. Poor problem-solving ability is a characteristic of conditions affecting executive functioning like dementia, rather than schizophrenia.

2. A nurse is preparing to administer insulin glargine to a client who has diabetes mellitus. Which of the following actions should the nurse take?

• A. Administer the insulin via IV push.
• B. Rotate injection sites to prevent tissue damage.
• C. Mix the insulin with regular insulin before administering it.
• D. Administer the insulin at the same time each day.

Correct answer: D

Rationale: Corrected Rationale: The correct action for the nurse to take when administering insulin glargine is to give it at the same time each day. This consistent timing helps maintain stable blood glucose levels. Choice A is incorrect because insulin glargine should not be administered via IV push. Choice B is incorrect as rotating injection sites is typically done for short-acting insulins to prevent lipodystrophy, not for insulin glargine. Choice C is incorrect as insulin glargine should not be mixed with other insulins before administration.

3. A client receiving a blood transfusion develops a fever. What action should the nurse take?

• A. Stop the transfusion immediately.
• B. Administer an antihistamine as prescribed.
• C. Administer a diuretic as prescribed.
• D. Increase the transfusion rate.

Correct answer: A

Rationale: When a client receiving a blood transfusion develops a fever, the priority action for the nurse is to stop the transfusion immediately. A fever during a blood transfusion may indicate a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Administering an antihistamine (choice B) or a diuretic (choice C) without assessing and addressing the potential transfusion reaction can be harmful. Increasing the transfusion rate (choice D) is contraindicated as it can exacerbate any adverse reactions the client is experiencing.

4. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse include?

• A. The cord stump will fall off in 5 days.
• B. Contact the provider if the cord stump turns black.
• C. Clean the base of the cord with hydrogen peroxide daily.
• D. Keep the cord stump dry until it falls off.

Correct answer: D

Rationale: The correct instruction for cord care is to keep the cord stump dry until it falls off. This helps prevent infection and promotes healing. Choice A is incorrect because the timing of when the cord stump falls off can vary, usually between 1-3 weeks. Choice B is incorrect as a black cord stump can be a normal part of the healing process, so it is unnecessary to contact the provider for this reason. Choice C is incorrect because cleaning the cord with hydrogen peroxide daily is not recommended as it can delay healing and cause irritation.

5. A client is 2 days postoperative following a hip replacement surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Redness and warmth in the calf
• C. Urine output of 30 mL/hr
• D. Heart rate of 96/min

Correct answer: B

Rationale: Redness and warmth in the calf can indicate a deep vein thrombosis (DVT), which is a serious complication following hip replacement surgery. It is crucial to report this finding promptly for further evaluation and intervention. The other options, heart rates of 88/min and 96/min, are within normal limits for an adult and may not require immediate reporting. A urine output of 30 mL/hr is concerning for decreased kidney perfusion, but the priority in this case is the potential DVT due to its severe implications.

Similar Questions