Nursing Elites

1. A nurse is caring for several clients with dehydration. The nurse assesses the client with which finding as needing oxygen therapy?

• A. Tenting of skin on the back of the hand
• B. Increased urine osmolarity
• C. Weight loss of 10 pounds
• D. Pulse rate of 115 beats/min

Correct answer: D

Rationale: The correct answer is the pulse rate of 115 beats/min. A rapid pulse rate is a sign of compensatory mechanisms in response to dehydration, indicating that the body is trying to deliver oxygen more efficiently. Oxygen therapy may be needed to support the increased oxygen demand. Tenting of skin on the back of the hand is a classic sign of dehydration due to decreased skin turgor. Increased urine osmolarity and weight loss are also indicators of dehydration, but they do not directly suggest a need for oxygen therapy.

2. A client is hospitalized with a urinary tract infection (UTI). Which clinical manifestation alerts the nurse to the possibility of a complication from the UTI?

• A. Burning on urination
• B. Cloudy, dark urine
• C. Fever and chills
• D. Hematuria

Correct answer: C

Rationale: Fever and chills are systemic symptoms that may indicate a more severe infection or a complication of a urinary tract infection (UTI). While burning on urination and cloudy, dark urine are common symptoms of UTI, fever and chills suggest a more serious condition requiring immediate attention. Hematuria, which is blood in the urine, is also a concerning symptom but is more indicative of inflammation or infection rather than a complication.

3. The nurse is caring for a hospitalized client who has AIDS and is severely immune compromised. Which interventions are used to help prevent infection in this client? (Select one that doesn't apply.)

• A. Use sterile gloves and gowns whenever the nursing staff is in contact with the client.
• B. Keep a blood pressure cuff, thermometer, and stethoscope in the client's room for his or her use only
• C. Request that the family take home the fresh flowers that are at the client's bedside
• D. Assist the client with meticulous oral care after meals and at bedtime.

Correct answer: A

Rationale:

4. The nurse is caring for a client who has had surgery the previous day. The client tells the nurse, "Breathing in using this thing (incentive spirometer) is a ridiculous waste of time."? What is the nurse's best response?

• A. "The spirometer will help you cough effectively."?
• B. "The spirometer will help your lungs expand."?
• C. "The spirometer will help prevent blood clots."?
• D. "The spirometer will improve blood flow in your lungs."?

Correct answer: B

Rationale: The correct answer is, '"The spirometer will help your lungs expand."?' Incentive spirometry is used postoperatively to help prevent atelectasis by expanding the lungs and improving lung function. Choice A is incorrect because the primary purpose of the spirometer is not to help cough effectively. Choice C is incorrect because while deep breathing with the spirometer can indirectly help prevent blood clots by improving lung function, its primary purpose is not to prevent blood clots directly. Choice D is incorrect because although using the spirometer can improve ventilation and oxygenation, its main purpose is not to improve blood flow in the lungs.

5. The nurse is planning care for a client with epilepsy. Which precautions does the nurse implement to ensure the safety of the client while in the hospital? (Select one that doesn't apply.)

• A. Have suction equipment at the bedside
• B. Keep bed rails up at all times
• C. Ensure that the client has IV access
• D. Maintain the client on strict bed rest

Correct answer: D

Rationale: For a client with epilepsy, it is essential to avoid restraining them with strict bed rest as it can lead to complications like muscle atrophy, thrombosis, and pressure ulcers. Having suction equipment at the bedside is important in case of seizures to prevent aspiration. Keeping bed rails up can prevent falls during a seizure. Ensuring that the client has IV access is crucial for administering medications such as antiepileptic drugs or emergency medications if needed. Therefore, maintaining the client on strict bed rest is not a recommended precaution for a client with epilepsy.

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