Nursing Elites

1. What is the appropriate intervention for a patient experiencing hypovolemic shock?

• A. Administer IV fluids
• B. Monitor blood pressure
• C. Place the patient in Trendelenburg position
• D. Administer oxygen

Correct answer: A

Rationale: The correct intervention for a patient experiencing hypovolemic shock is to administer IV fluids. In hypovolemic shock, there is a significant loss of circulating blood volume leading to inadequate perfusion to tissues. Administering IV fluids is crucial to restore blood volume and improve tissue perfusion. Monitoring blood pressure (choice B) is important but not the primary intervention in hypovolemic shock. Placing the patient in Trendelenburg position (choice C) can worsen outcomes by increasing intracranial pressure and is no longer recommended. Administering oxygen (choice D) is beneficial for many conditions but does not address the underlying issue of inadequate circulating blood volume in hypovolemic shock.

2. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

• A. Blood glucose level of 120 mg/dL
• B. White blood cell count of 8,000/mm³
• C. Temperature of 37.2°C (99°F)
• D. Daily weight increase of 0.45 kg (1 lb)

Correct answer: D

Rationale: The correct answer is D. A sudden weight increase may indicate fluid retention, a complication of TPN therapy that should be reported. Options A, B, and C are within normal ranges and do not directly relate to TPN therapy complications. A blood glucose level of 120 mg/dL is normal, a white blood cell count of 8,000/mm³ is within the normal range, and a temperature of 37.2°C (99°F) is also normal.

3. How should a healthcare professional manage a patient with an indwelling urinary catheter?

• A. Monitor urine output and ensure proper drainage
• B. Administer antibiotics and change the catheter regularly
• C. Monitor for signs of infection and provide catheter care
• D. Provide high-sodium diet and monitor hydration

Correct answer: A

Rationale: Monitoring urine output and ensuring proper catheter drainage are crucial aspects of managing a patient with an indwelling urinary catheter. This helps in assessing the patient's renal function, fluid balance, and the patency of the catheter. Administering antibiotics and changing the catheter regularly (Choice B) may not be necessary unless there is an infection present. While monitoring for signs of infection and providing catheter care (Choice C) are important, the primary focus should be on urine output and drainage. Providing a high-sodium diet and monitoring hydration (Choice D) are not directly related to managing an indwelling urinary catheter.

4. A nurse is caring for a client following an acute myocardial infarction who is concerned about fatigue. What is the best strategy to promote independence in self-care?

• A. Instruct the client to remain in bed until the fatigue resolves
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Assign assistive personnel to perform all self-care tasks for the client
• D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote independence while managing fatigue. This approach allows the client to regain confidence in their abilities and fosters independence. Option A is incorrect as prolonged bed rest can lead to deconditioning and worsen fatigue. Option C is not promoting independence as it involves delegating all self-care tasks to others. Option D involves family assistance, which may be helpful but does not directly promote the client's independence in self-care.

5. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching?

• A. HbA1c level greater than 8%.
• B. Blood glucose level greater than 200 mg/dL at bedtime.
• C. Blood glucose level less than 60 mg/dL before breakfast.
• D. HbA1c level less than 7%.

Correct answer: D

Rationale: The correct answer is D. An HbA1c level less than 7% indicates good long-term glucose control for clients with diabetes. This goal reflects optimal glycemic control and reduces the risk of long-term complications. Choices A, B, and C are incorrect because they do not represent appropriate goals for managing type 1 diabetes in an adolescent. An HbA1c level greater than 8% (choice A) signifies poor glucose control, while a blood glucose level greater than 200 mg/dL at bedtime (choice B) and a blood glucose level less than 60 mg/dL before breakfast (choice C) are not within the target ranges for safe and effective diabetes management.

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