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 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. A client with iron-deficiency anemia is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should increase my intake of foods high in iron.
• B. I should decrease my intake of foods high in iron.
• C. I should increase my intake of foods high in calcium.
• D. I should decrease my intake of foods high in calcium.

Correct answer: A

Rationale: The correct answer is A: 'I should increase my intake of foods high in iron.' Iron-deficiency anemia is managed by increasing the consumption of iron-rich foods to improve iron levels in the body. Foods high in iron include red meat, poultry, fish, beans, lentils, and iron-fortified cereals. Choices B, C, and D are incorrect because decreasing intake of iron-rich foods or increasing intake of calcium-rich foods would not address the deficiency in iron levels that characterizes iron-deficiency anemia.

4. A healthcare professional is preparing to administer an intramuscular injection to a client. Which of the following actions should the healthcare professional take?

• A. Use a 1-inch needle.
• B. Stretch the skin at the injection site.
• C. Insert the needle at a 90-degree angle.
• D. Aspirate for blood return before injecting.

Correct answer: D

Rationale: Aspirating for blood return before injecting is a crucial step in administering intramuscular injections. This action ensures that the needle is not in a blood vessel, reducing the risk of injecting medication into a blood vessel, which can lead to potential complications. Choices A, B, and C are incorrect. Using a longer 1-inch needle is often necessary for intramuscular injections to reach the muscle tissue properly. Stretching the skin is not recommended as it can cause unnecessary pain and tissue damage. Inserting the needle at a 90-degree angle is the preferred method for intramuscular injections to ensure proper medication delivery.

5. A client has a stage 1 pressure ulcer on the right heel. Which of the following interventions should the nurse include in the plan?

• A. Apply a heat lamp to the area for 20 minutes each day.
• B. Change the dressing on the heel every 12 hours.
• C. Apply a transparent dressing over the heel.
• D. Use a water pressure mattress.

Correct answer: C

Rationale: Applying a transparent dressing over the heel is beneficial as it can protect the ulcer from friction and shear, and allow for continuous observation of the wound. This intervention promotes healing and prevents further damage to the skin. Choice A is incorrect because applying heat can increase the risk of tissue damage and should be avoided. Choice B is incorrect as changing the dressing every 12 hours may disrupt the wound healing process and is not necessary for a stage 1 pressure ulcer. Choice D is incorrect because using a water pressure mattress is not a specific intervention for a stage 1 pressure ulcer on the heel.

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