Nursing Elites

1. A nurse is caring for a client who is in the early stages of hypovolemic shock. Which of the following findings should the nurse expect?

• A. Heart rate 60/min
• B. Increased urinary output
• C. Increased respiratory rate
• D. Hypothermia

Correct answer: C

Rationale: In the early stages of hypovolemic shock, the body initiates compensatory mechanisms to maintain perfusion. One of these mechanisms is an increased respiratory rate to improve oxygen delivery. This helps to offset the decreased circulating blood volume. A heart rate of 60/min (choice A) is not expected in hypovolemic shock; instead, tachycardia is a common finding due to the body's attempt to maintain cardiac output. Increased urinary output (choice B) is not typically seen in hypovolemic shock as the body tries to conserve fluid. Hypothermia (choice D) is usually a late sign of shock when the body's compensatory mechanisms are failing, and perfusion is severely compromised.

2. A nurse at a long-term care facility is transcribing new prescriptions for four clients. Which of the following prescriptions is accurately transcribed by the nurse?

• A. KCl 10 mEq PO once daily
• B. KCl 20 mEq PO once daily
• C. Potassium gluconate PO
• D. Potassium chloride 20 mEq PO every morning

Correct answer: D

Rationale: The correct answer is D because it accurately transcribes the prescription by specifying the medication (Potassium chloride), the dose (20 mEq), the route (PO for by mouth), and the frequency (every morning). Choice A is incorrect as it specifies a lower dose compared to the correct prescription. Choice B is incorrect due to an inaccurate dose. Choice C is incorrect as it lacks specificity regarding the type of potassium prescribed and the dose.

3. What are the key signs of hyperglycemia?

• A. Increased thirst and frequent urination
• B. Decreased appetite and low blood pressure
• C. Weight loss and nausea
• D. Increased sweating and confusion

Correct answer: A

Rationale: The correct answer is A: Increased thirst and frequent urination. These are classic signs of hyperglycemia, indicating elevated blood sugar levels. Choice B is incorrect as hyperglycemia usually presents with increased appetite rather than decreased appetite and low blood pressure. Choice C is incorrect as weight loss is more commonly associated with uncontrolled diabetes rather than hyperglycemia. Choice D is incorrect as increased sweating and confusion are not typical signs of hyperglycemia.

4. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include?

• A. Document the client's condition every 15 minutes.
• B. Attach the restraints to a non-moving part of the bed.
• C. Avoid requesting a PRN restraint prescription for clients who are aggressive.
• D. Remove the client's restraints based on the client's condition.

Correct answer: A

Rationale: The correct answer is A: Document the client's condition every 15 minutes. When using belt restraints, it is crucial to document the client's condition regularly to ensure their safety and well-being. This guideline allows for ongoing assessment of the client's need for restraints and any potential adverse effects. Choice B is incorrect as restraints should not be attached to the bed frame but to a non-moving part of the bed to prevent harm in case of bed movement. Choice C is incorrect as PRN (as needed) restraint prescription should not be a routine practice and should only be considered after other interventions have been attempted. Choice D is incorrect as restraints should be removed and reevaluated based on the client's condition, not solely on a fixed time schedule.

5. Which of the following interventions should the nurse prioritize for a client with dementia who is at risk of falls?

• A. Use restraints to prevent the client from leaving the bed
• B. Use a bed exit alarm system to notify staff when the client attempts to leave the bed
• C. Encourage frequent ambulation with assistance
• D. Raise all four side rails to prevent falls

Correct answer: B

Rationale: The correct answer is B. Using a bed exit alarm system is a non-restrictive intervention that alerts staff when the client tries to leave the bed, promoting safety and preventing falls. Choice A is incorrect because using restraints can have adverse effects and should be avoided whenever possible. Choice C is not the priority for a client at risk of falls due to dementia as it may increase the risk of falls without proper supervision. Choice D is also not recommended as raising all four side rails can lead to restraint and should be used cautiously, if at all. Therefore, the best option is to use a bed exit alarm system to ensure the client's safety while allowing some freedom of movement.

Similar Questions