Nursing Elites

1. The healthcare provider is caring for a client with dehydration. Which assessment finding indicates that the client is responding to treatment?

• A. Dry mucous membranes
• B. Increased urine output
• C. Decreased heart rate
• D. Elevated blood pressure

Correct answer: B

Rationale: Increased urine output is the correct assessment finding that indicates the client is responding to treatment for dehydration. When a client is dehydrated, their urine output tends to decrease as the body tries to conserve fluids. Therefore, an increase in urine output suggests that the client's hydration status is improving. Dry mucous membranes (Choice A) are a sign of dehydration and would not indicate a positive response to treatment. Decreased heart rate (Choice C) and elevated blood pressure (Choice D) are not specific indicators of hydration status in a client with dehydration.

2. The nurse is teaching a client with newly diagnosed type 1 diabetes about insulin administration. Which statement by the client indicates a need for further teaching?

• A. I will rotate my injection sites to avoid lipodystrophy.
• B. I will check my blood sugar before meals and at bedtime.
• C. I will use the same needle for 3 days if I keep it clean.
• D. I will keep my insulin refrigerated until I need it.

Correct answer: C

Rationale: The correct answer is C because insulin needles should be disposed of after a single use to prevent infection. Reusing the same needle for three days can lead to infection and is not a safe practice. Choices A, B, and D demonstrate good understanding of insulin administration and diabetes management, so they do not indicate a need for further teaching.

3. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

• A. Activate the emergency fire alarm
• B. Extinguish the fire
• C. Evacuate the client
• D. Confine the fire

Correct answer: C

Rationale: The correct action for the nurse to take next, after confirming the fire, is to evacuate the client. In a fire situation, following the RACE mnemonic, the priority is to rescue or evacuate clients to ensure their safety. Activating the emergency fire alarm (Choice A) is important to alert others and the fire department, but evacuating the client takes precedence. Extinguishing the fire (Choice B) may put the nurse and client at risk and is best left to trained personnel. Confining the fire (Choice D) is not the nurse's responsibility; the focus should be on ensuring the client's safety by evacuating them.

4. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102°F), heart rate of 105/min, a soft tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse’s priority?

• A. Temperature
• B. Menses overdue
• C. Soft tender abdomen
• D. Heart rate

Correct answer: A

Rationale: The correct answer is A: Temperature. A high temperature of 39.2°C (102°F) indicates a fever, which can be a sign of infection or another serious condition. Investigating the cause of the fever is a priority to address any underlying health issue promptly. Menses overdue (choice B) could be relevant but is not as urgent as addressing a fever. A soft tender abdomen (choice C) is important but may be a consequence of the underlying condition causing the fever. Heart rate (choice D) is also significant, but the priority here is to identify the cause of the fever.

5. When transferring a postoperative client from the PACU following abdominal surgery, what action should the nurse take to move the client from the stretcher to the bed?

• A. Lock the wheels on both the bed and stretcher
• B. Adjust the bed to a low position
• C. Ask the client to assist in the transfer
• D. Use a transfer sheet without locking the wheels

Correct answer: A

Rationale: Locking the wheels on both the bed and stretcher is crucial for ensuring stability during the transfer process. This action is essential to prevent unexpected movement of the bed or stretcher, reducing the risk of injury to the client and facilitating a safe transfer. Adjusting the bed to a low position is important for the client's comfort and safety but does not directly address the immediate need for stability during the transfer. Asking the client to assist in the transfer may not be feasible immediately postoperatively, depending on their condition and the type of surgery they underwent. Using a transfer sheet without locking the wheels can introduce potential safety hazards as the bed or stretcher may move during the transfer, undermining the stability needed for a safe and effective transfer.

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