Nursing Elites

1. Which manifestation should the nurse expect to assess in a patient with fluid volume deficit?

• A. Headache and muscle cramps
• B. Dyspnea and respiratory crackles
• C. Increased pulse rate and blood pressure
• D. Orthostatic hypotension and flat neck veins

Correct answer: D

Rationale: Orthostatic hypotension and flat neck veins are classic manifestations of fluid volume deficit. When the body loses fluid, blood volume decreases, leading to decreased venous return to the heart, resulting in orthostatic hypotension and flat neck veins. Choices A, B, and C are more indicative of other conditions such as dehydration, respiratory issues, or compensatory mechanisms in response to hypovolemia, respectively.

2. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

• A. Proceed with treatment without obtaining written consent
• B. Contact the client's next of kin to obtain consent for treatment
• C. Have the client sign a consent for treatment
• D. Notify risk management before initiating treatment

Correct answer: A

Rationale: In emergency situations where a client is disoriented and has a cardiac arrhythmia, obtaining written consent may not be possible due to the urgency of the situation. The priority is to provide immediate treatment to ensure patient safety. Contacting the next of kin or having the client sign a consent form would cause unnecessary delays in providing critical care. Notifying risk management before initiating treatment is not the most appropriate action when dealing with a time-sensitive situation like a cardiac arrhythmia.

3. A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other clients, and visitors. Which of the following actions should the nurse take?

• A. Keep the client in their room with the door closed
• B. Contact a family member to come and sit with the client
• C. Place the client in a wheelchair with a lap tray
• D. Administer a sedative to the client

Correct answer: B

Rationale: When dealing with a client exhibiting disruptive behavior like yelling obscenities, involving a family member can provide emotional support and help in de-escalating the situation. Keeping the client isolated in their room (Choice A) may lead to further agitation. Placing the client in a wheelchair (Choice C) or administering a sedative (Choice D) should not be the first interventions for managing behavioral issues.

4. A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?

• A. Measuring oxygen saturation for a client who has dyspnea
• B. Inserting a rectal suppository for a client who is vomiting
• C. Performing nasal hygiene for a client who has an NG tube
• D. Pouching a client's ostomy bag for a new colostomy

Correct answer: D

Rationale: Pouching a new colostomy is a task that can be safely and appropriately delegated to an assistive personnel as it falls within their scope of practice. Measuring oxygen saturation (Choice A) requires a higher level of training and assessment, making it unsuitable for delegation. Inserting a rectal suppository (Choice B) and performing nasal hygiene (Choice C) involve invasive procedures that are typically performed by licensed nursing staff due to the associated risks and complexities, making them inappropriate for delegation to assistive personnel.

5. Wilms' tumor is a form of:

• A. Renal cancer.
• B. Liver cancer.
• C. Basal cell carcinoma.
• D. Brain cancer.

Correct answer: A

Rationale: Wilms' tumor is a type of kidney cancer that primarily affects children. The correct answer is A: Renal cancer. This tumor originates in the kidneys and is most commonly found in children, with the peak incidence around 3-4 years of age. Choice B, Liver cancer, is incorrect as Wilms' tumor specifically involves the kidneys, not the liver. Choice C, Basal cell carcinoma, is a form of skin cancer, not related to Wilms' tumor. Choice D, Brain cancer, is incorrect as Wilms' tumor is not associated with the brain but rather with the kidneys.

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