Nursing Elites

1. A nurse is caring for a client who has dehydration. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Hypotension
• C. Dry mucous membranes
• D. Tachypnea

Correct answer: C

Rationale: Correct! Dry mucous membranes are a common finding in clients with dehydration. Dehydration leads to reduced fluid volume in the body, resulting in dryness of mucous membranes, decreased skin turgor, and thirst. Bradycardia (slow heart rate) is not typically associated with dehydration, as the body tries to compensate for decreased fluid volume by increasing heart rate. Hypotension (low blood pressure) is a possible finding in dehydration due to reduced circulating volume. Tachypnea (rapid breathing) is more commonly seen in conditions like respiratory distress or metabolic acidosis, rather than dehydration.

2. A client has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

• A. Take this medication with food to reduce stomach upset.
• B. Inject this medication into the muscle.
• C. Massage the injection site after administering the medication.
• D. Inject this medication into the abdomen.

Correct answer: D

Rationale: The correct answer is D because enoxaparin should be injected into the abdomen to ensure proper absorption. Choice A is incorrect as enoxaparin should not be taken with food. Choice B is incorrect as enoxaparin should be injected subcutaneously, not into the muscle. Choice C is incorrect as massaging the injection site after administering enoxaparin is not recommended.

3. A nurse is planning care for a client who has tuberculosis. Which of the following actions should the nurse take to prevent the transmission of the disease?

• A. Place the client in droplet isolation.
• B. Place the client in airborne isolation.
• C. Wear a surgical mask when providing care to the client.
• D. Keep the client's door closed at all times.

Correct answer: B

Rationale: The correct answer is B: 'Place the client in airborne isolation.' Tuberculosis is an airborne disease transmitted through droplet nuclei. Placing the client in airborne isolation helps prevent the spread of the disease to others. Choice A, placing the client in droplet isolation, is incorrect because tuberculosis is not transmitted through large droplets. Choice C, wearing a surgical mask when providing care to the client, is not sufficient as airborne precautions are necessary. Choice D, keeping the client's door closed at all times, does not directly address the prevention of disease transmission in this case.

4. A nurse is planning care for a client with thrombocytopenia. Which action should the nurse include in the care plan?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to increased bleeding tendencies. Providing a stool softener helps prevent constipation and straining during bowel movements, reducing the risk of bleeding. Encouraging the client to floss daily (Choice A) is important for oral hygiene but is not directly related to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to preventing infections in immunocompromised clients. Avoiding serving raw vegetables (Choice D) is important for clients with compromised immune systems but is not specifically targeted at managing thrombocytopenia.

5. A nurse is assessing a client who is in active labor. The FHR baseline has been 100/min for the past 15 minutes. What condition should the nurse suspect?

• A. Maternal fever.
• B. Fetal anemia.
• C. Maternal hypoglycemia.
• D. Chorioamnionitis.

Correct answer: C

Rationale: In this scenario, the FHR baseline of 100/min for the past 15 minutes indicates fetal bradycardia, which can be caused by maternal hypoglycemia. Maternal hypoglycemia can lead to decreased oxygen supply to the fetus, resulting in fetal bradycardia. Maternal fever (Choice A) typically presents with tachycardia in the fetus rather than bradycardia. Fetal anemia (Choice B) is more likely to manifest as tachycardia due to compensation for decreased oxygen delivery. Chorioamnionitis (Choice D) may lead to fetal tachycardia as a sign of fetal distress, not bradycardia.

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