Nursing Elites

1. A client is experiencing mild anxiety. Which of the following findings should the nurse expect?

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

Correct answer: B

Rationale: In clients experiencing mild anxiety, a heightened perceptual field is a common finding. This means that the individual may be more alert and observant of their surroundings, sometimes to the point of being hyper-aware. Choices A, C, and D are less likely to be associated with mild anxiety. Feelings of dread (Choice A) are more commonly seen in moderate to severe anxiety. Rapid speech (Choice C) may be observed in some cases of anxiety, but it is not a specific hallmark of mild anxiety. Purposeless activity (Choice D) is more indicative of severe anxiety or other mental health conditions.

2. A client with diabetes mellitus is receiving education from a nurse on preventing long-term complications. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will keep my blood glucose levels within the target range.
• B. I will check my feet daily for any open sores or wounds.
• C. I will monitor my blood pressure regularly.
• D. I will consume foods that are high in fiber.

Correct answer: B

Rationale: The correct answer is B: 'I will check my feet daily for any open sores or wounds.' This statement shows an understanding of the importance of foot care in preventing complications like diabetic foot ulcers. Monitoring blood glucose levels (choice A) is crucial but not directly related to foot care. Monitoring blood pressure (choice C) is important for overall health but does not specifically address preventing long-term complications of diabetes. Consuming foods high in fiber (choice D) is beneficial for managing blood sugar levels but does not directly address preventing foot complications.

3. A nurse is assessing a client who has a deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?

• A. Calf tenderness.
• B. Shortness of breath.
• C. Elevated blood pressure.
• D. Respiratory rate of 18/min.

Correct answer: B

Rationale: Shortness of breath is a critical finding that can indicate a pulmonary embolism, a severe complication of DVT. This symptom suggests a potential life-threatening situation and requires immediate intervention. Calf tenderness, while common in DVT, is not as urgent as shortness of breath. Elevated blood pressure and a respiratory rate of 18/min are important to assess but are not typically as indicative of a serious complication like a pulmonary embolism.

4. What is the best way to monitor fluid balance in a patient receiving diuretics?

• A. Monitor daily weight
• B. Monitor intake and output
• C. Monitor blood pressure
• D. Check for edema

Correct answer: A

Rationale: Corrected Rationale: Daily weight monitoring is the most accurate way to assess fluid balance in patients receiving diuretics. Monitoring daily weight allows healthcare providers to track changes in fluid status more precisely. While monitoring intake and output (choice B) is essential, it may not provide a comprehensive picture of overall fluid balance. Monitoring blood pressure (choice C) is important but may not directly reflect fluid balance. Checking for edema (choice D) is useful but may not be as sensitive as daily weight monitoring in assessing fluid balance.

5. A healthcare professional is preparing to administer an IV bolus of morphine to a client. Which of the following actions should the healthcare professional take first?

• A. Check the client's respiratory rate.
• B. Administer naloxone.
• C. Check the client's pain level.
• D. Assess the client's blood pressure.

Correct answer: A

Rationale: Correct Answer: Checking the client's respiratory rate is the priority before administering morphine because morphine can depress respiration. This action helps the healthcare professional assess the client's baseline respiratory status and detect any potential respiratory depression that may be exacerbated by morphine. Choice B, administering naloxone, is incorrect because naloxone is used as an antidote for opioid overdose and not routinely administered before giving morphine. Choice C, checking the client's pain level, is important but not the first action to take before administering morphine. Choice D, assessing the client's blood pressure, is also important but not the initial priority compared to evaluating respiratory status when preparing to administer morphine.

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