Nursing Elites

1. A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?

• A. Monitor the client's intake and output every 6 hours
• B. Administer furosemide to the client
• C. Check the client's IV infusion every 8 hours
• D. Offer the client 240 ml (8 oz) of oral fluids every 4 hours

Correct answer: D

Rationale: Offering the client 240 ml (8 oz) of oral fluids every 4 hours is essential to maintain hydration in a client with dehydration who is receiving continuous IV infusion. This intervention helps ensure an adequate fluid balance. Monitoring the client's intake and output every 6 hours is necessary to assess hydration status and response to treatment. Administering furosemide to the client, choice B, is contraindicated in dehydration as it can further deplete fluid volume. Checking the IV infusion every 8 hours, as in choice C, is important but not as critical as ensuring oral fluid intake to promote hydration.

2. How should a healthcare professional assess a patient's pain who is non-verbal?

• A. Looking for changes in vital signs that may indicate pain
• B. Using alternative methods like touch or distraction
• C. Using a pain scale appropriate for non-verbal patients
• D. Observing for facial expressions or other non-verbal cues

Correct answer: A

Rationale: When assessing pain in non-verbal patients, looking for changes in vital signs that may indicate pain is crucial. While using alternative methods like touch or distraction can be helpful, they may not directly indicate the presence of pain. Using a pain scale appropriate for non-verbal patients is important, but it may not always provide immediate feedback. Observing for facial expressions or other non-verbal cues can be subjective and may not always accurately reflect the level of pain the patient is experiencing. Therefore, monitoring vital signs is a more objective way to assess pain in non-verbal patients.

3. A nurse at a local health department is caring for a client who is newly diagnosed with listeriosis. Which of the following actions should the nurse plan to take?

• A. Provide the Centers for Disease Control (CDC) and Prevention with the client's information
• B. Inform the client that they are required to have health department staff directly observe their treatment
• C. Determine whether the condition is reportable under state requirements
• D. Find out whether the condition is endemic in the client's neighborhood

Correct answer: C

Rationale: The correct answer is C: 'Determine whether the condition is reportable under state requirements.' Listeriosis is a reportable disease, meaning healthcare providers are legally required to report cases to public health authorities. By checking the state requirements for reportable diseases, the nurse ensures compliance with public health regulations. Choice A is incorrect because providing the client's information to the CDC is not the immediate action needed. Choice B is incorrect as direct observation of treatment is not a standard procedure for listeriosis. Choice D is also incorrect as determining if the condition is endemic in the client's neighborhood is not the primary concern when managing a diagnosed case of listeriosis.

4. A client expresses concern about hair loss during chemotherapy. What should the nurse suggest?

• A. Encourage the client to cut their hair short before chemotherapy begins.
• B. Offer resources for wigs and head coverings.
• C. Assure the client that hair loss will be minimal.
• D. Ignore the client's concerns about hair loss.

Correct answer: B

Rationale: During chemotherapy, hair loss is a common side effect. Offering resources for wigs and head coverings can help the client cope with this change in appearance, maintain self-esteem, and feel more comfortable during the process. Encouraging the client to cut their hair short does not address the emotional impact of hair loss and may not be the client's preference. Assuring the client that hair loss will be minimal may provide false hope as significant hair loss is a common occurrence. Ignoring the client's concerns is not appropriate and goes against the principles of providing holistic and compassionate care.

5. A nurse is teaching a client about signs of infection after surgery. What statement indicates further teaching is required?

• A. Redness and swelling are normal after surgery
• B. Any drainage from the incision site is not concerning
• C. Yellow drainage is normal
• D. I should monitor for increased redness or warmth

Correct answer: B

Rationale: The correct answer is B. Any drainage from the incision site should be monitored, and any signs of infection, such as increased redness or warmth, need to be reported to the healthcare provider. Choices A, C, and D provide accurate information about signs of infection after surgery and do not indicate a need for further teaching.

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