Nursing Elites

1. A client is being assessed for dehydration. Which of the following findings should the nurse expect?

• A. Elevated blood pressure
• B. Increased skin turgor
• C. Dark-colored urine
• D. Bradypnea

Correct answer: C

Rationale: Dark-colored urine is a common sign of dehydration as the urine becomes concentrated. Dehydration leads to reduced fluid intake or excessive fluid loss, causing the urine to be darker in color due to increased urine concentration. Elevated blood pressure (Choice A) is not typically associated with dehydration; instead, dehydration often leads to low blood pressure. Increased skin turgor (Choice B) is actually a sign of good hydration, not dehydration. Bradypnea (Choice D), which refers to abnormally slow breathing, is not a common finding in dehydration.

2. A client receives education on dietary management for ulcerative colitis from a nurse. Which of the following statements should the nurse include in the teaching?

• A. You should increase your intake of high-fiber foods.
• B. You should avoid foods containing lactose.
• C. You should decrease your intake of dairy products.
• D. You should increase your intake of dairy products.

Correct answer: C

Rationale: The correct statement the nurse should include in the teaching is to decrease the intake of dairy products. This is because reducing the intake of dairy products is beneficial in managing symptoms of ulcerative colitis. Dairy products can aggravate symptoms due to their lactose content, thus advising the client to decrease their consumption can help alleviate discomfort and promote better management of the condition.\nChoice A is incorrect because increasing high-fiber foods may worsen symptoms in some individuals with ulcerative colitis.\nChoice B is incorrect as while it is advised to avoid foods containing lactose, this alone does not encompass the full dietary management for ulcerative colitis.\nChoice D is incorrect as increasing the intake of dairy products can exacerbate symptoms in individuals with ulcerative colitis due to their lactose content.

3. A healthcare professional is preparing to administer an IM injection to a client. Which of the following techniques should the healthcare professional use to reduce discomfort?

• A. Use a 25-gauge needle.
• B. Administer the injection slowly.
• C. Massage the site after the injection.
• D. Apply ice to the injection site before administration.

Correct answer: B

Rationale: Administering the injection slowly is the recommended technique to reduce discomfort associated with IM injections. This approach allows the medication to disperse more gradually into the muscle, minimizing the sensation of pressure or pain during administration. Administering the injection slowly can also help prevent tissue damage and reduce the likelihood of injection site reactions.

4. During an abdominal assessment, what is the correct sequence of steps for a healthcare provider to follow?

• A. Inspection, percussion, palpation, auscultation
• B. Percussion, auscultation, inspection, palpation
• C. Auscultation, palpation, inspection, percussion
• D. Inspection, auscultation, percussion, palpation

Correct answer: D

Rationale: During an abdominal assessment, the correct sequence of steps is inspection, auscultation, percussion, and palpation. This sequence is followed to prevent altering bowel sounds. Inspection allows for visual observation, followed by auscultation to listen for bowel sounds without causing disturbance, percussion to assess for tympany or dullness, and finally palpation to feel for any abnormalities or tenderness. Choice A is incorrect because palpation should come after percussion. Choice B is incorrect as auscultation should be performed after inspection. Choice C is incorrect because palpation should be the final step after percussion.

5. A client has been on bed rest for 3 days. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

• A. The client uses a walker to move from the bed to the chair.
• B. The client has a strong cough.
• C. The client can bear weight on both legs.
• D. The client has a normal respiratory rate.

Correct answer: C

Rationale: The ability to bear weight on both legs indicates muscle strength and stability necessary for ambulation. This skill is crucial for the client to support their body weight and move independently when standing or walking. Choices A, B, and D are incorrect because using a walker, having a strong cough, or having a normal respiratory rate do not directly indicate the readiness to ambulate. The key factor in determining readiness for ambulation is the client's ability to bear weight on both legs, demonstrating the necessary strength for standing and walking.

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