Nursing Elites

1. A nurse is caring for a client who is experiencing fluid volume deficit (FVD). What clinical finding should the nurse expect?

• A. Decreased hematocrit
• B. Increased heart rate
• C. Increased blood pressure
• D. Decreased respiratory rate

Correct answer: B

Rationale: Increased heart rate is a common sign of fluid volume deficit (FVD) as the body compensates for decreased fluid levels. When a client is experiencing FVD, the body tries to maintain perfusion to vital organs by increasing the heart rate. This compensatory mechanism helps to improve cardiac output and maintain blood pressure. Choices A, C, and D are incorrect because in FVD, hematocrit may be increased due to hemoconcentration, blood pressure tends to decrease as a compensatory response to FVD, and respiratory rate is usually unaffected or may increase due to attempts to maintain oxygenation.

2. When teaching a client about the correct use of a cane, what should the nurse include?

• A. Hold the cane on the weaker side
• B. Ensure the cane has a rubber tip
• C. Keep the cane on the dominant side
• D. Use the cane only on stairs

Correct answer: B

Rationale: The correct answer is B. When instructing a client on the use of a cane, it is essential to ensure that the cane has a rubber tip. This rubber tip helps prevent slipping, providing additional stability and safety. Option A, holding the cane on the weaker side, is incorrect as the cane should be held on the stronger side to provide better balance and support. Option C, keeping the cane on the dominant side, is also incorrect because the cane should be held on the stronger side. Option D, using the cane only on stairs, is not comprehensive as the cane can be used for support and balance while walking on level ground as well.

3. A client scheduled for cataract surgery tells the nurse, 'I see just fine and have decided to cancel my surgery.' What should the nurse do?

• A. Proceed with the surgery as planned
• B. Document the refusal and inform the surgeon
• C. Explain the benefits of the surgery
• D. Respect the client's decision

Correct answer: C

Rationale: In this scenario, the nurse should explain the benefits of the surgery to the client. By providing more information, the client may reconsider their decision after understanding the positive impact the surgery could have on their vision. Proceeding with the surgery against the client's wishes (Choice A) is not ethical and goes against the principle of autonomy. While documenting the refusal and informing the surgeon (Choice B) is important for the client's medical record, it is crucial to first try to educate the client about the benefits. Simply respecting the client's decision (Choice D) without attempting to provide more information may not be in the client's best interest.

4. A healthcare professional is reviewing the laboratory values of a client who is experiencing fluid volume deficit (FVD). What finding should the professional expect?

• A. Decreased hematocrit
• B. Increased hematocrit
• C. Decreased white blood cell count
• D. Increased red blood cell count

Correct answer: B

Rationale: The correct answer is 'Increased hematocrit.' In fluid volume deficit (FVD), there is a decrease in the amount of fluid in the blood vessels, leading to hemoconcentration. This results in an increase in hematocrit levels. Choices A, C, and D are incorrect because a decrease in hematocrit, decrease in white blood cell count, and an increase in red blood cell count are not typically seen in fluid volume deficit.

5. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?

• A. Bladder spasms
• B. Bladder distention
• C. Frequent urination
• D. Hematuria

Correct answer: B

Rationale: The correct answer is B: Bladder distention. Bladder distention is a sign of catheter occlusion because it indicates a failure to drain urine properly. Bladder spasms (Choice A) are more commonly associated with bladder irritability rather than catheter occlusion. Frequent urination (Choice C) is unlikely in a client with an indwelling catheter as the urine should be draining continuously. Hematuria (Choice D) refers to blood in the urine and is not typically a direct sign of catheter occlusion.

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