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 nurse is caring for a client who is in severe pain. Which of the following questions should the nurse ask first?

• A. How severe is your pain on a scale of 1 to 10?
• B. Where is your pain located?
• C. What medication are you taking for the pain?
• D. When did the pain start?

Correct answer: B

Rationale: The correct answer is B: 'Where is your pain located?' When a client is experiencing severe pain, determining the location of the pain is crucial as it helps the nurse identify potential causes and select appropriate interventions. Option A may be important but assessing the location of pain takes precedence as it can provide valuable information for immediate management. Option C focuses on the current treatment, which is important but not the first priority. Option D, knowing when the pain started, is relevant but does not help in immediate pain management.

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. A client is scheduled for a 12-lead ECG. Which of the following actions should the nurse include in the plan of care?

• A. Ensure the client is fasting before the test
• B. Provide a warm blanket for the client
• C. Apply cold compresses to the client's chest
• D. Instruct the client to remain still

Correct answer: D

Rationale: During a 12-lead ECG, the client needs to remain still to obtain accurate readings. Therefore, instructing the client to remain still is essential. Choices A, B, and C are incorrect because fasting is not necessary for an ECG, providing a warm blanket is not a standard procedure, and applying cold compresses may interfere with the ECG results.

5. What should a healthcare professional prioritize when managing a client with delirium?

• A. Administering sedative medication
• B. Providing a low-stimulation environment
• C. Identifying the underlying cause of the delirium
• D. Controlling behavioral symptoms with medication

Correct answer: C

Rationale: When managing a client with delirium, the priority should be to identify the underlying cause of the delirium. Delirium can result from various triggers such as infections, medication side effects, or metabolic imbalances. By determining the root cause, healthcare professionals can provide targeted treatment and improve outcomes. Administering sedative medication (Choice A) could exacerbate delirium as these drugs can worsen confusion. While providing a low-stimulation environment (Choice B) is beneficial, it is not as critical as identifying the cause. Controlling behavioral symptoms with medication (Choice D) should only be considered after identifying and addressing the underlying cause of delirium.

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