Nursing Elites

1. What is the right to make one's own personal decisions, even though those decisions might not be in the person's best interest?

• A. Autonomy
• B. Non-maleficence
• C. Justice
• D. Beneficence

Correct answer: A

Rationale: The correct answer is A: Autonomy. Autonomy is the right to make one's own decisions, even if they may not be in the person's best interest. Autonomy emphasizes an individual's freedom to choose and act according to their own values and beliefs. Non-maleficence (B) refers to the principle of 'do no harm,' Justice (C) refers to fairness and equality in the distribution of resources or benefits, and Beneficence (D) refers to the obligation to do good and act in the patient's best interest.

2. A nurse is caring for a client who has hypokalemia. Which of the following clinical findings should the nurse expect?

• A. Hyperactive reflexes.
• B. Strong, bounding pulse.
• C. Decreased bowel sounds.
• D. Increased deep tendon reflexes.

Correct answer: C

Rationale: The correct answer is C: Decreased bowel sounds. In hypokalemia, decreased bowel sounds are common due to slowed peristalsis. Hyperactive reflexes (choice A) and increased deep tendon reflexes (choice D) are more indicative of hyperkalemia. A strong, bounding pulse (choice B) is not typically associated with hypokalemia.

3. A nurse is caring for a client who has pneumonia and new onset confusion. Which of the following actions should the nurse take first?

• A. Increase the client's oxygen flow rate
• B. Obtain the client's vital signs
• C. Administer an antibiotic
• D. Notify the provider

Correct answer: A

Rationale: Correct Answer: Increasing the client's oxygen flow rate should be the nurse's first action. Hypoxia is a common complication of pneumonia and can lead to confusion. Providing adequate oxygenation is essential in addressing hypoxia and improving the client's condition.\nOption B: Obtaining vital signs is important but addressing hypoxia takes precedence in the setting of new onset confusion.\nOption C: Administering an antibiotic is important for treating pneumonia but addressing hypoxia and confusion is the priority.\nOption D: Notifying the provider may be necessary but addressing the immediate physiological need of oxygenation should come first.

4. What is the most appropriate response when a client with chronic kidney disease asks about fluid restrictions?

• A. Fluid restrictions are not needed for all clients with chronic kidney disease.
• B. You may need to limit fluid intake to prevent fluid overload.
• C. Fluid restrictions are based on your lab results and daily weights.
• D. Restricting fluids is only necessary during dialysis.

Correct answer: B

Rationale: The most appropriate response when a client with chronic kidney disease asks about fluid restrictions is to inform them that limiting fluid intake may be necessary to prevent fluid overload. This is crucial in managing the condition and preventing complications such as edema and electrolyte imbalances. Choice A is incorrect as fluid restrictions are commonly advised for clients with chronic kidney disease. Choice C is partially correct as fluid restrictions are indeed based on lab results and daily weights, but the primary goal is to prevent fluid overload. Choice D is incorrect because fluid restrictions are not limited to just during dialysis; they are often recommended throughout the day to manage the condition.

5. A client who had a vaginal delivery 4 hours ago has a fourth-degree perineal laceration. Which of the following interventions should the nurse recommend?

• A. Encourage ambulation
• B. Apply ice packs
• C. Restrict the client's fluid intake
• D. Administer stool softeners

Correct answer: B

Rationale: Correct Answer: Applying ice packs is the most appropriate intervention for a client with a fourth-degree perineal laceration. Ice packs help reduce swelling and promote comfort, aiding in the healing process. Choice A, encouraging ambulation, may not be suitable immediately after a fourth-degree laceration due to the need for rest and proper wound care. Choice C, restricting fluid intake, is not indicated and can lead to dehydration, which is not beneficial for wound healing. Choice D, administering stool softeners, may be necessary to prevent constipation and straining, but it is not the priority intervention at this time.

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