Nursing Elites

1. How should a healthcare provider assess a patient with sepsis?

• A. Monitor vital signs and administer fluids
• B. Monitor for fever and administer antibiotics
• C. Check for tachycardia and elevated white blood cell count
• D. Administer fluids and provide nutritional support

Correct answer: A

Rationale: In sepsis, it is crucial to monitor vital signs to assess the patient's condition and administer fluids to maintain circulation. This approach helps in stabilizing blood pressure and perfusion. While monitoring for fever and administering antibiotics (choice B) is important in managing sepsis, the initial priority lies in assessing and stabilizing the patient's hemodynamic status. Checking for tachycardia and elevated white blood cell count (choice C) can be part of the assessment but does not encompass the immediate intervention needed in sepsis. Administering fluids and providing nutritional support (choice D) are essential in managing sepsis, but the primary step should be to assess the patient's condition through vital sign monitoring.

2. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

• A. Administer the medication into the client's nondominant arm.
• B. Pull the skin laterally before inserting the needle.
• C. Massage the injection site after administration.
• D. Pinch the skin between the thumb and forefinger.

Correct answer: D

Rationale: The correct action the nurse should take when administering enoxaparin subcutaneously is to pinch the skin between the thumb and forefinger. Pinching the skin helps to lift the subcutaneous tissue, reducing the risk of injecting into the muscle. Choices A, B, and C are incorrect. Choice A is not relevant as the injection site for enoxaparin is typically in the abdomen or thigh, not the arm. Choice B is incorrect as pulling the skin laterally is not a recommended technique for subcutaneous injections. Choice C is also incorrect as massaging the injection site after administration can increase the risk of bleeding or bruising.

3. Which symptom would indicate a complication after a subdural hematoma?

• A. Increased appetite
• B. Decreased level of consciousness
• C. High-pitched cry
• D. Bulging posterior fontanelle

Correct answer: B

Rationale: A bulging posterior fontanelle is a sign of increased intracranial pressure in infants, not a common symptom after a subdural hematoma. In the context of a subdural hematoma, a decreased level of consciousness is more indicative of a complication as it can be a sign of worsening brain function due to increased pressure on the brain from the collection of blood in the subdural space. Increased appetite and high-pitched cry are not typically associated with complications of a subdural hematoma.

4. A charge nurse is teaching new staff members about factors that increase a client's risk of becoming violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

• A. Experiencing delusions.
• B. Male gender.
• C. Previous violent behavior.
• D. A history of being in prison.

Correct answer: C

Rationale: The correct answer is C: Previous violent behavior. This is considered the best predictor of future violent actions as individuals who have a history of violent behavior are more likely to engage in violent acts again. Option A, experiencing delusions, although it can impact behavior, is not as strong of a predictor as past violent behavior. Option B, male gender, is a demographic factor but not as specific or predictive as a history of violence. Option D, a history of being in prison, may indicate past behavior but is not directly linked to future violent actions as a known history of violence.

5. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching?

• A. HbA1c level greater than 8%.
• B. Blood glucose level greater than 200 mg/dL at bedtime.
• C. Blood glucose level less than 60 mg/dL before breakfast.
• D. HbA1c level less than 7%.

Correct answer: D

Rationale: The correct answer is D. An HbA1c level less than 7% indicates good long-term glucose control for clients with diabetes. This goal reflects optimal glycemic control and reduces the risk of long-term complications. Choices A, B, and C are incorrect because they do not represent appropriate goals for managing type 1 diabetes in an adolescent. An HbA1c level greater than 8% (choice A) signifies poor glucose control, while a blood glucose level greater than 200 mg/dL at bedtime (choice B) and a blood glucose level less than 60 mg/dL before breakfast (choice C) are not within the target ranges for safe and effective diabetes management.

Similar Questions