Nursing Elites

1. What are the signs of hypovolemic shock and what is the nurse's role in management?

• A. Rapid pulse, low blood pressure; administer IV fluids
• B. Cold extremities, rapid breathing; administer oxygen
• C. Decreased urine output, sweating; administer diuretics
• D. Weak pulse, clammy skin; administer vasopressors

Correct answer: A

Rationale: The correct signs of hypovolemic shock are a rapid pulse and low blood pressure. Administering IV fluids helps to restore circulating volume, which is essential in managing hypovolemic shock. Choice B is incorrect because cold extremities and rapid breathing are not typical signs of hypovolemic shock. Choice C is incorrect as administering diuretics would further decrease circulating volume, worsening the condition. Choice D is incorrect as administering vasopressors may further compromise perfusion in hypovolemic shock.

2. A client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take?

• A. Encourage the client to lie down in a quiet room.
• B. Ask the client directly what they are hearing.
• C. Tell the client that the voices are not real.
• D. Provide headphones for the client to listen to music.

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with schizophrenia experiencing auditory hallucinations is to ask the client directly what they are hearing. This approach helps the nurse gain insight into the client's experience, establish effective communication, and provide appropriate support. Encouraging the client to lie down in a quiet room (Choice A) may not address the hallucinations directly. Telling the client that the voices are not real (Choice C) can be invalidating and may lead to further distress. Providing headphones for music (Choice D) may not be effective in addressing the client's hallucinations.

3. A client has hyperthermia. Which of the following actions should the nurse take?

• A. Submerge the client's feet in ice water.
• B. Cover the client with a thermal blanket.
• C. Administer oral acetaminophen.
• D. Initiate seizure precautions.

Correct answer: C

Rationale: Administering oral acetaminophen is the appropriate intervention for a client with hyperthermia. Acetaminophen helps to reduce fever by lowering the body's temperature. Submerging the client's feet in ice water can lead to shock and is not recommended. Using a thermal blanket may worsen the condition by trapping heat. Initiating seizure precautions is not directly related to managing hyperthermia.

4. What is the priority for a client with dehydration?

• A. Administer antiemetics to prevent nausea
• B. Monitor electrolyte levels to prevent imbalances
• C. Administer oral rehydration solutions
• D. Administer intravenous fluids

Correct answer: B

Rationale: The priority for a client with dehydration is to monitor electrolyte levels to prevent imbalances. Dehydration can lead to electrolyte disturbances, which can have serious consequences. Administering antiemetics (Choice A) may help with nausea but does not address the root cause of dehydration. Administering oral rehydration solutions (Choice C) can be beneficial, but monitoring electrolyte levels is crucial in managing dehydration. Administering intravenous fluids (Choice D) is important in severe cases of dehydration, but monitoring electrolytes should come first to assess the extent of the imbalance and guide fluid replacement therapy effectively.

5. What are the nursing interventions for a patient experiencing hypoglycemia?

• A. Administer glucose or dextrose and monitor blood sugar levels
• B. Monitor vital signs and provide a high-carbohydrate snack
• C. Monitor for sweating and confusion
• D. Provide insulin and assess for hyperglycemia

Correct answer: A

Rationale: The correct answer is A. Administering glucose or dextrose is a crucial nursing intervention for a patient experiencing hypoglycemia as it helps to quickly raise blood sugar levels. Monitoring blood sugar levels is essential to ensure that the patient's glucose levels normalize. Choice B is incorrect because providing a high-carbohydrate snack may not be sufficient to rapidly raise blood sugar levels in severe hypoglycemia. Choice C is incorrect because while monitoring for sweating and confusion is important in hypoglycemia, it is not a direct nursing intervention. Choice D is incorrect as providing insulin would lower blood sugar levels further, worsening hypoglycemia.

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