Nursing Elites

1. Mang David, A 27 year old psychiatric client was admitted with a diagnosis of schizophrenia. During the morning assessment, Mang David shouted “Did you know that I am the top salesman in the world? Different companies want me!” As a nurse, you know that this is an example of:

• A. Hallucination
• B. Delusion
• C. Confabulation
• D. Flight of Ideas

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

2. A healthcare professional is reviewing the laboratory findings of a client who has heart failure. Which of the following findings indicates that the client is experiencing fluid volume excess?

• A. BUN 8 mg/dL
• B. Hgb 15 g/dL
• C. Creatinine 0.8 mg/dL
• D. Sodium 140 mEq/L

Correct answer: A

Rationale: A BUN level of 8 mg/dL indicates fluid volume excess in a client with heart failure. BUN (Blood Urea Nitrogen) levels can be low in fluid overload due to hemodilution, a common occurrence in heart failure. High levels of BUN usually indicate dehydration or impaired renal function, which are not the case in fluid volume excess. Choices B, C, and D are within normal ranges and do not specifically indicate fluid volume excess.

3. A child with ear problem should be assessed for the following, EXCEPT:

• A. is there any fever?
• B. Ear discharge
• C. If discharge is present for how long?
• D. Ear pain

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

4. What is the glomerular filtration rate for patients with stage 5 chronic kidney disease (CKD)?

• A. Less than 15 mL/min/1.73 m²
• B. Less than 30 mL/min/1.73 m²
• C. Less than 90 mL/min/1.73 m²
• D. Less than 125 mL/min/1.73 m²

Correct answer: A: Less than 15 mL/min/1.73 m²

Rationale: In patients with stage 5 chronic kidney disease (CKD), also known as end-stage renal disease, the kidney function is significantly compromised. This severe condition is characterized by a glomerular filtration rate (GFR) of less than 15 mL/min/1.73 m², as correctly stated in choice A. Choices B, C, and D suggest higher GFR values, which are not indicative of stage 5 CKD. Specifically, a GFR of less than 30 mL/min/1.73 m² indicates stage 4 CKD, less than 90 mL/min/1.73 m² signifies stage 3 CKD, and a typical healthy individual usually has a GFR of around 125 mL/min/1.73 m², which is far above the GFR for stage 5 CKD.

5. Where should a nurse auscultate the apex beat?

• A. At the fifth intercostal space, along the midclavicular line
• B. At the mid-sternum
• C. 2 inches to the left of the lower end of the sternum
• D. 1 inch to the left of the xiphoid process

Correct answer: A

Rationale: The correct location to auscultate the apex beat is at the fifth intercostal space, along the midclavicular line. This is where the apical impulse, also known as the point of maximal impulse (PMI), can be best heard. Choices B, C, and D are incorrect anatomical locations for auscultating the apex beat, which makes them incorrect choices. Auscultating at the correct location allows healthcare providers to assess the heart's function and detect any abnormalities in heart sounds, which is crucial for comprehensive patient care.

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