Nursing Elites

1. How should a healthcare professional assess and manage a patient with dehydration?

• A. Assess skin turgor and monitor intake/output
• B. Encourage oral fluids only
• C. Administer IV fluids immediately
• D. Check for electrolyte imbalance and administer fluids

Correct answer: A

Rationale: The correct way to assess and manage a patient with dehydration is to assess skin turgor and monitor intake/output. Skin turgor assessment helps in evaluating the degree of dehydration, while monitoring intake/output aids in maintaining fluid balance. Encouraging oral fluids only (Choice B) may not be sufficient for moderate to severe dehydration as patients may need intravenous fluids (IV) to rapidly rehydrate. Administering IV fluids immediately (Choice C) is not always the first step unless the patient is severely dehydrated. Checking for electrolyte imbalance and administering fluids (Choice D) is important but comes after assessing skin turgor and intake/output in the management of dehydration.

2. When should a healthcare provider suction a client's tracheostomy?

• A. When the client is hypotensive
• B. When the client is irritable
• C. When the client is flushed
• D. When the client is bradycardic

Correct answer: B

Rationale: Irritability is an early sign that suctioning is required to clear secretions in a client with a tracheostomy. Hypotension, flushing, and bradycardia are not direct indicators for suctioning a tracheostomy. Hypotension may indicate a need for fluid resuscitation or other interventions, flushing could be due to various reasons like fever, and bradycardia may require evaluation for cardiac causes.

3. A healthcare provider is reviewing the medical record of a client who has hypertension. Which of the following findings should the provider identify as a risk factor for this condition?

• A. Age 25 years
• B. Family history of hypotension
• C. Obesity
• D. History of hypotension

Correct answer: C

Rationale: The correct answer is C: Obesity. Obesity is a significant risk factor for hypertension due to its impact on the cardiovascular system. Obesity can lead to increased blood pressure due to the additional workload placed on the heart and blood vessels. Age alone does not necessarily predispose someone to hypertension, and a family history of hypotension or a personal history of hypotension would not increase the risk of developing hypertension. Family history of hypotension is not a known risk factor for hypertension, and a history of hypotension actually indicates low blood pressure, which is the opposite of hypertension.

4. What are the risk factors for pressure ulcer development?

• A. Immobility and poor nutrition
• B. Obesity and diabetes
• C. Dehydration and malnutrition
• D. Use of assistive devices and prolonged bedrest

Correct answer: A

Rationale: Corrected Rationale: The correct answer is immobility and poor nutrition. Immobility can lead to constant pressure on certain areas of the body, while poor nutrition can impair tissue repair and regeneration, both contributing to the development of pressure ulcers. Choices B, C, and D are incorrect because while obesity, diabetes, dehydration, malnutrition, use of assistive devices, and prolonged bedrest can impact skin integrity and wound healing, they are not the primary risk factors specifically associated with pressure ulcer development.

5. A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer oxytocin
• B. Perform fundal massage
• C. Administer IV fluids
• D. Call the provider

Correct answer: B

Rationale: Performing fundal massage is the priority action in this scenario. Fundal massage helps contract the uterus, which is essential in reducing excessive lochia postpartum. Administering oxytocin may be indicated later, but fundal massage should be the initial intervention to address the issue. Administering IV fluids may not directly address the cause of excessive lochia, and calling the provider should come after implementing immediate nursing interventions.

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