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1. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
- A. Blood pressure 144/82 mm Hg
- B. Urine specific gravity 1.03
- C. Neck vein distention
- D. Urine specific gravity 1.01
Correct answer: A
Rationale: In a client experiencing vomiting and diarrhea, the nurse should expect findings such as dehydration, which can lead to hypovolemia and subsequent increased heart rate and decreased blood pressure. A blood pressure of 144/82 mm Hg is indicative of possible dehydration in this client. Urine specific gravity is typically increased in dehydrated individuals, so choices B and D are incorrect. Neck vein distention is not a typical finding associated with vomiting and diarrhea; therefore, choice C is also incorrect.
2. A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?
- A. Hydrocolloid
- B. Transparent
- C. Gauze
- D. Alginate
Correct answer: A
Rationale: The correct answer is A: Hydrocolloid. For a stage 2 pressure injury, a hydrocolloid dressing is recommended. Hydrocolloid dressings provide a moist environment that promotes healing and is effective for wounds with moderate exudate. Choice B (Transparent) is not typically used for stage 2 pressure injuries as it is more suitable for superficial wounds. Choice C (Gauze) is not ideal for stage 2 pressure injuries as it can adhere to the wound bed and cause trauma upon removal. Choice D (Alginate) is more appropriate for wounds with heavy exudate, not typically seen in stage 2 pressure injuries.
3. The staff in the emergency department has presented the nurse leader with a suggestion for streamlining the triage process, cutting down on wait times. Which of the following qualities does the leader specifically need to implement the suggestion?
- A. Courage
- B. Integrity
- C. Energy
- D. Initiative
Correct answer: D
Rationale: Initiative is the correct quality needed in this situation. The staff has provided a suggestion for improvement, and the leader must take the initiative to implement it. Courage, integrity, and energy are valuable qualities as well but in this context, the most essential quality is initiative to drive the change forward and improve the triage process efficiently.
4. After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective?
- A. �I may feel hungrier than usual when I take this medicine.�
- B. �I will not need to worry about hypoglycemia with the Byetta.�
- C. �I should take my daily aspirin at least an hour before the Byetta.�
- D. �I will take the pill at the same time I eat breakfast in the morning.�
Correct answer: C
Rationale:
5. During a discussion about the nursing profession at a middle school, which of the following statements is true?
- A. Nurses need to graduate from nursing school to earn a degree.
- B. Nursing is a profession that values continuous education.
- C. Nurses function autonomously within their scope of practice.
- D. Nurses must adhere to professional behaviors in all aspects of their lives.
Correct answer: C
Rationale: The correct answer is C. Nurses are healthcare professionals who can independently make decisions within their defined scope of practice, providing care to patients. This autonomy allows nurses to assess, diagnose, plan, intervene, and evaluate patient care without direct supervision from physicians. Choice A is incorrect because nurses need to graduate from nursing school to earn a degree, not necessarily to obtain a license. Choice B is incorrect because while continuous education is important in nursing, it is not a defining characteristic of the profession. Choice D is incorrect because while nurses are expected to adhere to professional behaviors, it is not limited to their professional lives but extends to their personal lives as well.
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