Nursing Elites

1. A nurse is caring for a client who is experiencing fluid volume deficit (FVD). What clinical finding should the nurse expect?

• A. Decreased hematocrit
• B. Increased heart rate
• C. Increased blood pressure
• D. Decreased respiratory rate

Correct answer: B

Rationale: Increased heart rate is a common sign of fluid volume deficit (FVD) as the body compensates for decreased fluid levels. When a client is experiencing FVD, the body tries to maintain perfusion to vital organs by increasing the heart rate. This compensatory mechanism helps to improve cardiac output and maintain blood pressure. Choices A, C, and D are incorrect because in FVD, hematocrit may be increased due to hemoconcentration, blood pressure tends to decrease as a compensatory response to FVD, and respiratory rate is usually unaffected or may increase due to attempts to maintain oxygenation.

2. A client at risk for pressure injuries is being cared for by a nurse. What intervention should the nurse implement?

• A. Keep the client in one position
• B. Use a special mattress for the client
• C. Turn the client every 4 hours
• D. Provide extra pillows for positioning

Correct answer: B

Rationale: The correct intervention for a client at risk for pressure injuries is to use a special mattress. Special mattresses help reduce the risk of pressure injuries by redistributing pressure on bony areas, thus preventing tissue damage. Keeping the client in one position (choice A) can actually increase the risk of pressure injuries due to prolonged pressure on specific areas. Turning the client every 4 hours (choice C) is important for preventing pressure injuries, but using a special mattress is a more effective intervention. Providing extra pillows for positioning (choice D) may offer some comfort but does not address the primary intervention of pressure redistribution that a special mattress provides.

3. A client has a new prescription for a cane. What instruction should the nurse include?

• A. Hold the cane on the weaker side
• B. Ensure the cane has a rubber tip
• C. Keep the cane on the dominant side
• D. Use the cane only on stairs

Correct answer: B

Rationale: The correct answer is B: 'Ensure the cane has a rubber tip.' This instruction is essential for safety as the rubber tip prevents slipping, providing stability. Choice A is incorrect because the cane should be held on the stronger side to provide better support and balance. Choice C is incorrect as the cane should be used on the stronger, more dominant side. Choice D is also incorrect as a cane is not only used on stairs but also for general support and mobility.

4. A healthcare professional is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the professional use?

• A. Gait belt
• B. Mechanical lift
• C. Stand-assist lift
• D. Slide board

Correct answer: C

Rationale: A stand-assist lift is the most suitable device for transferring a client who can bear partial weight and has upper body strength. This lift provides support and assistance for clients to stand up and be safely transferred. A gait belt is used for providing support during walking or transferring short distances for clients who need minimal assistance with balance and strength. A mechanical lift is typically used for clients who are non-weight bearing or have limited weight-bearing capacity. A slide board is utilized for transferring clients who are unable to bear weight on their legs and need assistance in sliding from one surface to another.

5. A nurse is updating a plan of care for a client who has dysphagia. What intervention should the nurse include?

• A. Encourage the client to lie down after eating
• B. Offer the client liquids with meals
• C. Have the client sit upright for 1 hour after meals
• D. Provide the client with a straw for drinking

Correct answer: C

Rationale: The correct intervention for a client with dysphagia is to have them sit upright for 1 hour after meals. This position helps facilitate swallowing and reduces the risk of aspiration, which is crucial in managing dysphagia. Encouraging the client to lie down after eating (Choice A) can increase the risk of aspiration. Offering liquids with meals (Choice B) may also increase the risk of aspiration as it can affect swallowing coordination. Providing the client with a straw for drinking (Choice D) is not recommended as straws can increase the risk of aspiration in individuals with dysphagia.

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