Nursing Elites

1. A healthcare professional is assessing a client with severe dehydration. Which finding indicates a need for immediate intervention?

• A. Heart rate of 110 beats per minute.
• B. Blood pressure of 90/60 mm Hg.
• C. Urine output of 20 ml/hour.
• D. Dry mucous membranes.

Correct answer: C

Rationale: A urine output of 20 ml/hour indicates severe dehydration and impaired renal function. This finding suggests a critical state where the kidneys are conserving water, leading to reduced urine output. Immediate intervention is required to restore fluid balance and prevent further complications associated with severe dehydration. Choice A, a heart rate of 110 beats per minute, may indicate dehydration but is not as severe as the critically low urine output. Choice B, a blood pressure of 90/60 mm Hg, can be seen in dehydration but is not as concerning as the extremely low urine output. Choice D, dry mucous membranes, is a common sign of dehydration but does not require immediate intervention compared to the severely reduced urine output.

2. The client is receiving intravenous (IV) morphine for pain control. Which assessment finding requires the most immediate intervention?

• A. Drowsiness.
• B. Itching.
• C. Nausea.
• D. Respiratory rate of 8 breaths per minute.

Correct answer: D

Rationale: A respiratory rate of 8 breaths per minute indicates severe respiratory depression, a life-threatening side effect of opioid therapy. Immediate intervention is crucial to prevent respiratory failure. Monitoring and managing respiratory status are critical in clients receiving opioids to prevent adverse events. Drowsiness, itching, and nausea are common side effects of morphine but are not as immediately life-threatening as severe respiratory depression.

3. A client with hyperthyroidism is prescribed propylthiouracil (PTU). Which instruction should the nurse include in the client's discharge teaching?

• A. Report any signs of infection, such as sore throat or fever, to your healthcare provider.'
• B. Increase your intake of iodine-rich foods, such as seafood and dairy products.'
• C. Take the medication on an empty stomach for better absorption.'
• D. You may experience weight gain and fatigue as side effects of the medication.'

Correct answer: A

Rationale: Propylthiouracil (PTU) can suppress bone marrow function, increasing the risk of infection, so it is important to report signs of infection promptly.

4. An 85-year-old male resident of an extended care facility reaches for the hand of an unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation?

• A. This behavior can be considered sexual harassment and should be reported to the administration immediately.
• B. The UAP should be reassigned to another group of residents, preferably females only.
• C. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need.
• D. The resident needs to understand the rules regarding unwanted touching of the staff and the consequences.

Correct answer: C

Rationale: In this scenario, the resident's actions of reaching for the UAP's hand and trying to kiss it could indicate a need for touch rather than intentional sexual harassment. The best assessment is to consider the possibility that the client may be experiencing touch deprivation and is seeking appropriate ways to express his need for physical contact. Providing guidance on acceptable ways to seek physical affection can help address the underlying issue and improve the resident's interactions with the staff. Choice A is incorrect because assuming sexual harassment without understanding the context and potential reasons behind the behavior can lead to misinterpretation. Choice B is inappropriate as reassignment based on gender is not a solution and does not address the root cause of the behavior. Choice D is not the best approach as it focuses solely on setting boundaries without considering the resident's underlying need for touch.

5. A client with hepatic encephalopathy is being treated with lactulose. What is an expected outcome of this treatment?

• A. Reduction in blood ammonia levels
• B. Improvement in liver enzyme levels
• C. Decrease in bilirubin levels
• D. Increase in urine output

Correct answer: A

Rationale: Lactulose is used to treat hepatic encephalopathy by reducing blood ammonia levels through promoting its excretion via the intestines. Elevated ammonia levels contribute to the development of encephalopathy symptoms, so by lowering them, the client's neurological status can improve.

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