Nursing Elites

1. A nurse overhears two assistive personnel (APs) discussing a client in a hospital cafeteria, using the client’s name and discussing details of the diagnosis. Which of the following actions should the nurse take first?

• A. Report the APs' behavior to the supervisor
• B. Complete an incident report regarding the APs' conversation
• C. Provide the APs with written documentation on confidentiality
• D. Tell the APs to discontinue their conversation

Correct answer: D

Rationale: The correct action for the nurse to take first is to tell the APs to discontinue their conversation. By stopping the conversation immediately, the nurse addresses the breach of client confidentiality on the spot. This action is crucial to protect the client's privacy and confidentiality. While further steps such as reporting the behavior or providing education on confidentiality may be necessary, the immediate priority is to stop the inappropriate discussion. Reporting the behavior to the supervisor or completing an incident report can come after the immediate issue is addressed. Providing written documentation on confidentiality may be helpful but is not the most urgent action needed in this situation.

2. A healthcare professional is assessing a client for potential complications after surgery. Which of the following should the healthcare professional monitor for?

• A. Decreased urine output
• B. Increased appetite
• C. Improved mobility
• D. Normal temperature

Correct answer: A

Rationale: Corrected Rationale: Decreased urine output can indicate renal complications or dehydration, which are common post-surgical complications. Monitoring urine output is crucial for detecting early signs of kidney dysfunction or fluid imbalances. Increased appetite, improved mobility, and normal temperature are not typical signs of immediate post-surgical complications and would not be the priority for monitoring in this case.

3. A nurse is assessing a 2-hour-old newborn for cold stress. Which of the following findings should the nurse expect?

• A. Respiratory rate of 60/min
• B. Jitteriness of the hands
• C. Diaphoresis
• D. Bounding peripheral pulses

Correct answer: B

Rationale: The correct answer is B: Jitteriness of the hands. Jitteriness is a key sign of cold stress in a newborn, indicating the need for immediate warming measures. A respiratory rate of 60/min may not be directly indicative of cold stress. Diaphoresis (excessive sweating) and bounding peripheral pulses are not typical findings associated with cold stress in newborns.

4. A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following interventions should the nurse implement?

• A. Encourage frequent ambulation
• B. Administer lorazepam
• C. Provide a low-calorie diet
• D. Administer insulin as prescribed

Correct answer: B

Rationale: The correct intervention for a client experiencing alcohol withdrawal is to administer lorazepam. Lorazepam, a benzodiazepine, is commonly used to manage the symptoms of alcohol withdrawal by preventing seizures and reducing agitation and anxiety. Encouraging frequent ambulation (choice A) may not be safe during alcohol withdrawal due to potential instability and confusion. Providing a low-calorie diet (choice C) is not a priority during alcohol withdrawal, as the focus is on managing withdrawal symptoms. Administering insulin as prescribed (choice D) is unrelated to managing alcohol withdrawal symptoms.

5. A nurse in an outpatient facility is assessing a client who is prescribed furosemide 40 mg daily, but the client reports she has been taking extra doses to promote weight loss. Which of the following indicates she is dehydrated?

• A. Urine specific gravity of 1.035
• B. Oliguria, increased urine concentration, and an increase in urine specific gravity greater than 1.030
• C. Polyuria
• D. Hypotension

Correct answer: B

Rationale: Oliguria (reduced urine output), increased urine concentration, and a urine specific gravity greater than 1.030 are indicative of dehydration, particularly in clients using diuretics excessively. Choice A is incorrect because a urine specific gravity of 1.035 is high, indicating concentrated urine but not specifically dehydration. Choice C, polyuria, refers to increased urine output and is not consistent with dehydration. Choice D, hypotension, is a sign of fluid volume deficit but is not specific to dehydration as described in the scenario.

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