Nursing Elites

1. What is the nurse's role in preoperative patient care?

• A. Provide patient education and ensure NPO status
• B. Ensure that informed consent is obtained
• C. Obtain the patient's health history
• D. Confirm the patient's surgical site

Correct answer: A

Rationale: The nurse plays a crucial role in preoperative patient care by providing education and ensuring NPO (nothing by mouth) status. This helps prepare the patient for surgery by ensuring they understand the procedure, what to expect, and also by following necessary preoperative fasting guidelines. While obtaining the patient's health history (choice C) is important for overall patient assessment, it is typically done during the preoperative assessment but does not specifically pertain to the nurse's role. Ensuring informed consent (choice B) is primarily the responsibility of the healthcare provider performing the procedure. Confirming the patient's surgical site (choice D) is usually the responsibility of the surgical team and is done immediately before the surgery to prevent errors.

2. A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be

• A. Confused with cold, clammy skin and a pulse of 110
• B. Lethargic with hot, dry skin and rapid, deep respirations
• C. Alert and cooperative with a BP of 130/80 and respirations of 12
• D. Short of breath, with distended neck veins and a bounding pulse of 96

Correct answer: A

Rationale: The correct answer is A. Low blood sugar levels (50 mg/dL) typically cause confusion, cold clammy skin, and an increased pulse (tachycardia). Option A correctly describes the expected symptoms of hypoglycemia, which include confusion due to the brain's inadequate glucose supply, cold and clammy skin due to sympathetic nervous system activation, and an increased pulse (110 bpm) as the body reacts to low blood sugar levels. Options B, C, and D describe symptoms that are not typically associated with hypoglycemia. Lethargy, hot dry skin, rapid deep respirations, normal vital signs, shortness of breath, distended neck veins, and bounding pulse are more indicative of other conditions or normal physiological responses, not hypoglycemia.

3. A nurse is reviewing the plan of care for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse include?

• A. Apply heat to the affected area
• B. Place the client in a prone position
• C. Turn and reposition the client every 2 hours
• D. Provide the client with a bedpan every 4 hours

Correct answer: C

Rationale: The correct intervention for a client at risk for pressure ulcers is to turn and reposition the client every 2 hours. This helps relieve pressure on bony prominences, improving circulation and reducing the risk of pressure ulcer development. Applying heat to the affected area (Choice A) can increase the risk of skin breakdown. Placing the client in a prone position (Choice B) can also increase pressure on certain areas, leading to pressure ulcers. Providing the client with a bedpan every 4 hours (Choice D) is not directly related to preventing pressure ulcers.

4. Which of the following interventions should the nurse implement for a client with dementia who is at risk of falling?

• A. Keep the bed in the lowest position
• B. Raise all four side rails to prevent falls
• C. Assist with ambulation every 2 hours
• D. Use a bed exit alarm to notify staff of attempts to leave the bed

Correct answer: D

Rationale: The correct intervention for a client with dementia at risk of falling is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention helps in preventing falls by alerting the staff when the client tries to get out of bed. Keeping the bed in the lowest position (Choice A) may not prevent falls and could make it challenging for staff to provide care. Raising all four side rails (Choice B) can be a restraint and is not recommended as it may lead to entrapment or other risks. Assisting with ambulation every 2 hours (Choice C) may not be feasible or effective in preventing falls, as the client may attempt to get out of bed at any time.

5. What are the differences between viral and bacterial infections?

• A. Viral infections often cause fatigue and body aches
• B. Bacterial infections often cause high fever and localized pain
• C. Viral infections are treated with antibiotics
• D. Bacterial infections are usually self-limiting

Correct answer: A

Rationale: Corrected Rationale: Viral infections often cause fatigue and body aches, while bacterial infections are more likely to cause high fever and localized pain. Choice A is the correct answer as it accurately reflects the symptoms commonly associated with viral infections. Bacterial infections, on the other hand, typically present with fever and localized pain, as stated in choice B. Choice C is incorrect as viral infections do not respond to antibiotics, while choice D is inaccurate because bacterial infections may require antibiotic treatment and are not always self-limiting.

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