Nursing Elites

1. While assessing a client with fluid volume deficit, which of the following findings should the nurse expect?

• A. Bradycardia
• B. Increased skin turgor
• C. Dry mucous membranes
• D. Hypertension

Correct answer: C

Rationale: Dry mucous membranes are a classic clinical manifestation of fluid volume deficit. Dehydration leads to reduced fluid intake or excessive fluid loss, resulting in decreased moisture in the mucous membranes. Bradycardia, increased skin turgor, and hypertension are not typically associated with fluid volume deficit. Bradycardia is more commonly seen in conditions like hypothyroidism or increased intracranial pressure. Increased skin turgor is a sign of dehydration, not deficit. Hypertension is not a typical finding in fluid volume deficit.

2. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

3. A client has a tracheostomy and requires suctioning. Which of the following actions should be taken?

• A. Hyperoxygenate the client before suctioning
• B. Insert the catheter while exhalation
• C. Apply suction after inserting the catheter
• D. Limit suctioning to no more than 15 seconds

Correct answer: A

Rationale: Hyperoxygenating the client before suctioning is crucial to prevent hypoxia during the procedure. By using a manual resuscitation bag with 100% oxygen, the nurse should provide several breaths to the client to ensure sufficient oxygenation before starting suctioning. This approach helps maintain oxygen levels and decreases the risk of hypoxia, which may arise when suctioning interrupts the normal respiratory process. Choices B, C, and D are incorrect because inserting the catheter during exhalation, applying suction while inserting the catheter, and limiting suctioning to 15 seconds do not address the priority of hyperoxygenating the client to prevent hypoxia.

4. When assessing a client with chronic pain, which of the following is the most reliable indicator of the client's pain?

• A. The client's vital signs.
• B. The client's self-report of pain.
• C. The client's body language.
• D. The client's medical history.

Correct answer: B

Rationale: The client's self-report of pain is the most reliable indicator of pain. Pain is a subjective experience, and the client's self-report provides direct insight into their perception of pain intensity, quality, and impact on daily life. Vital signs, body language, and medical history can offer additional information but may not accurately reflect the client's actual pain experience. Therefore, relying on the client's self-report ensures a more accurate assessment of their pain and helps in tailoring appropriate interventions and treatment plans.

5. When planning care for a client with a pressure ulcer, which intervention should the nurse include in the plan?

• A. Massage the reddened area.
• B. Apply a donut-shaped cushion.
• C. Reposition the client every 3 hours.
• D. Use a transparent film dressing.

Correct answer: D

Rationale: The correct intervention for a client with a pressure ulcer is to use a transparent film dressing. This dressing provides a protective barrier against external contaminants while allowing for wound inspection, promoting healing. Massaging the reddened area can cause further damage to the skin and should be avoided. Donut-shaped cushions can increase pressure on the ulcer site rather than alleviate it. Repositioning the client every 2 hours is a preventive measure for pressure ulcers, but once an ulcer has developed, using a transparent film dressing is a more appropriate intervention to facilitate healing and protect the wound site.

Similar Questions