Nursing Elites

1. How should signs of dehydration in an elderly patient be assessed?

• A. Monitor skin turgor
• B. Check for dry mucous membranes
• C. Monitor for sunken eyes
• D. Check capillary refill

Correct answer: A

Rationale: Corrected Rationale: Monitoring skin turgor is a reliable method to assess dehydration in elderly patients. Skin turgor refers to the skin's elasticity or the skin's ability to return to its normal position after being pinched. In dehydration, the skin loses its elasticity, becoming less flexible and slower to return to its original state. Checking for dry mucous membranes (Choice B), monitoring for sunken eyes (Choice C), and checking capillary refill (Choice D) are all relevant assessments in dehydration but are not as specific or sensitive as monitoring skin turgor. Dry mucous membranes and sunken eyes are indicators of dehydration, while capillary refill is more related to circulatory status and less specific to dehydration.

2. A healthcare professional is assessing a client receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the healthcare professional identify as an adverse effect of the medication?

• A. Diarrhea.
• B. Urinary retention.
• C. Hypotension.
• D. Bradycardia.

Correct answer: C

Rationale: Hypotension is a common adverse effect of morphine due to its vasodilatory properties. It can lead to a drop in blood pressure, which should be closely monitored during administration. Diarrhea (Choice A) is not a typical adverse effect of morphine. Urinary retention (Choice B) is a side effect of morphine due to its impact on the bladder muscles, but it is not classified as an adverse effect. Bradycardia (Choice D) is not a common adverse effect of morphine; instead, it tends to cause tachycardia.

3. A nurse is planning care for a client who has dehydration. Which of the following interventions should the nurse include?

• A. Monitor the client's fluid intake.
• B. Provide the client with a high-protein diet.
• C. Encourage the client to ambulate frequently.
• D. Administer 0.45% sodium chloride IV.

Correct answer: D

Rationale: The correct intervention for a client with dehydration is to administer 0.45% sodium chloride IV. This solution helps correct fluid imbalance by providing the necessary electrolytes. Restricting fluid intake (Choice A) is not appropriate for dehydration as the client needs adequate fluids to rehydrate. Providing a high-protein diet (Choice B) is not directly related to correcting dehydration. Encouraging the client to ambulate frequently (Choice C) is beneficial for overall health but does not address the issue of dehydration directly.

4. A nurse is reviewing the medical record of a client who has a new prescription for insulin glargine. Which of the following should the nurse include in the teaching?

• A. This insulin has a peak effect of 2 to 4 hours.
• B. This insulin has a duration of action of 24 hours.
• C. This insulin is given before meals to control your blood sugar.
• D. You should avoid eating 30 minutes before or after taking this insulin.

Correct answer: B

Rationale: The correct answer is B. Insulin glargine has a 24-hour duration of action, making it suitable for once-daily dosing for long-term blood sugar control. Choice A is incorrect as insulin glargine is a long-acting insulin with no pronounced peak effect in its action profile. Choice C is incorrect as insulin glargine is usually given at the same time each day regardless of meals. Choice D is incorrect as there is no specific requirement to avoid eating before or after taking insulin glargine.

5. What is the first intervention for a patient experiencing anaphylactic shock?

• A. Administer epinephrine
• B. Administer corticosteroids
• C. Administer antihistamines
• D. Administer oxygen

Correct answer: A

Rationale: The correct answer is to administer epinephrine as the first intervention for a patient experiencing anaphylactic shock. Epinephrine is crucial in reversing the allergic reaction and restoring cardiovascular stability. Corticosteroids (Choice B) are not the first-line treatment for anaphylactic shock but may be used as an adjunct therapy. Antihistamines (Choice C) can help relieve itching and hives but are not as effective as epinephrine in treating the systemic effects of anaphylaxis. Oxygen (Choice D) may be necessary to support breathing in severe cases of anaphylaxis, but administering epinephrine takes precedence in the management of anaphylactic shock.

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