Nursing Elites

1. A client is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates understanding?

• A. I can change my living will whenever I want.
• B. I do not need a living will if I have a durable power of attorney.
• C. My family will make decisions for me if I am unable to.
• D. I need a living will only if I am seriously ill.

Correct answer: A

Rationale: The correct answer is A because the client understanding that they can change their living will whenever they want shows comprehension of advance directives. Choices B, C, and D are incorrect: B is inaccurate as both documents serve different purposes; C may not always be the case based on the client's wishes and legal documents; D is incorrect because a living will is not only for serious illness but also for end-of-life care decisions.

2. A nurse is caring for a client who is postop following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?

• A. Increased fiber intake
• B. Decreased physical activity
• C. Frequent urge suppression
• D. Adequate sleep

Correct answer: B

Rationale: The correct answer is B: Decreased physical activity. Following abdominal surgery, reduced physical activity can contribute to constipation due to decreased bowel motility. Increased fiber intake (choice A) generally helps prevent constipation by adding bulk to the stool. Frequent urge suppression (choice C) may lead to issues like urinary retention but is not directly linked to constipation. Adequate sleep (choice D) is important for overall recovery but does not significantly impact constipation risk.

3. A nurse in an emergency department is monitoring the hydration status of a client receiving oral rehydration. What finding should the nurse intervene for?

• A. Heart rate of 80 beats per minute
• B. Heart rate of 120 beats per minute
• C. Blood pressure of 110/70 mmHg
• D. Respiratory rate of 16 breaths per minute

Correct answer: B

Rationale: A heart rate of 120 beats per minute indicates tachycardia, which can be a sign of dehydration and requires intervention. A heart rate of 80 beats per minute is within the normal range and does not indicate dehydration. A blood pressure of 110/70 mmHg is considered normal. A respiratory rate of 16 breaths per minute is also within the normal range and does not point towards dehydration.

4. A nurse is reviewing the lab report of a client who has been experiencing a fever for the last 3 days. What lab result indicates the client is experiencing fluid volume deficit (FVD)?

• A. Decreased BUN levels
• B. Increased hematocrit
• C. Increased white blood cell count
• D. Decreased hematocrit

Correct answer: B

Rationale: The correct answer is B: Increased hematocrit. Increased hematocrit indicates hemoconcentration, which is a sign of fluid volume deficit. When there is a decrease in fluid volume in the body, the blood becomes more concentrated, leading to an increase in hematocrit levels. Choices A, C, and D are incorrect because decreased BUN levels, increased white blood cell count, and decreased hematocrit are not indicative of fluid volume deficit.

5. A nurse is preparing to administer a medication through a nasogastric (NG) tube. What action should the nurse take first?

• A. Flush the NG tube with 60 mL of water
• B. Verify tube placement
• C. Crush the medications and dissolve them in water
• D. Administer all medications together

Correct answer: B

Rationale: Verifying tube placement is the priority before administering any medications through a nasogastric tube. This step ensures that the tube is correctly positioned in the stomach to prevent complications such as aspiration. Flushing the tube with water, crushing medications, or administering them together should only be done after confirming the correct placement of the NG tube. Therefore, option B is the correct first action to take in this scenario.

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