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 with a new diagnosis of type 2 diabetes mellitus is being taught about dietary management. Which of the following statements should the nurse include in the teaching?

• A. You should avoid foods that contain carbohydrates.
• B. You should decrease your intake of high-fiber foods.
• C. You should increase your intake of high-protein foods.
• D. You should monitor your carbohydrate intake.

Correct answer: D

Rationale: The correct answer is D: 'You should monitor your carbohydrate intake.' Monitoring carbohydrate intake is essential for managing blood glucose levels in clients with type 2 diabetes mellitus. By monitoring carbohydrate intake, individuals can make informed decisions about their dietary choices and better control their blood sugar levels. Avoiding foods that contain carbohydrates (choice A) is not advisable as carbohydrates are an essential nutrient that can be consumed in moderation. Decreasing intake of high-fiber foods (choice B) is not recommended as fiber is beneficial for glycemic control and overall health. Increasing intake of high-protein foods (choice C) is not the primary focus of dietary management for type 2 diabetes; while protein is important, it is more crucial to monitor carbohydrate intake for effective blood sugar management.

3. Which of the following statements indicates the client understands the colostomy care instructions?

• A. I will change the colostomy bag once a week.
• B. I will avoid eating high-fiber foods.
• C. I will clean around the stoma with mild soap and water.
• D. I will apply lotion to the skin around the stoma.

Correct answer: C

Rationale: The correct answer is C. Cleaning around the stoma with mild soap and water is crucial for colostomy care as it helps prevent infection and skin irritation. Changing the colostomy bag frequency, dietary modifications, or applying lotion are not primary aspects of stoma care. Proper cleaning around the stoma helps maintain hygiene and prevents complications, making it a key component of caring for a colostomy.

4. A healthcare professional is preparing to administer medications to a client who has an NG tube for continuous feedings. Which of the following actions should the healthcare professional take?

• A. Add crushed medications to the enteral feeding.
• B. Infuse each medication by gravity.
• C. Administer the medications through a syringe.
• D. Flush the NG tube with 5 mL of sterile water.

Correct answer: C

Rationale: Administering medications through a syringe is the correct action to take when a client has an NG tube for continuous feedings. This method ensures that each medication is delivered correctly and is not mixed with the enteral feeding, preventing drug interactions and ensuring proper administration of each medication. Adding crushed medications to the enteral feeding (Choice A) can lead to inaccurate dosing and potential drug interactions. Infusing each medication by gravity (Choice B) is not recommended as it may not ensure accurate delivery of the medication. Flushing the NG tube with sterile water (Choice D) is important but is not directly related to administering medications through the tube.

5. A healthcare professional is preparing to administer a subcutaneous injection. Which of the following actions should the healthcare professional take?

• A. Use a 1-inch needle.
• B. Insert the needle at a 90-degree angle.
• C. Use a tuberculin syringe.
• D. Aspirate before injecting.

Correct answer: B

Rationale: When administering a subcutaneous injection, it is important to insert the needle at a 90-degree angle to ensure proper medication delivery into the subcutaneous tissue. This angle helps prevent the medication from being injected too deeply or too superficially, ensuring optimal absorption and therapeutic effect. Choice A is incorrect because the needle length for a subcutaneous injection is typically shorter, around ⅝ to 1 inch. Choice C is incorrect as a tuberculin syringe is not commonly used for subcutaneous injections. Choice D is also incorrect as aspiration is not necessary for subcutaneous injections since there are minimal blood vessels in the subcutaneous tissue.

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