Nursing Elites

1. How should a healthcare professional assess a patient for dehydration?

• A. Check for skin turgor
• B. Monitor blood pressure
• C. Check for dry mucous membranes
• D. Monitor urine output

Correct answer: A

Rationale: Checking for skin turgor is a reliable method to assess dehydration in patients. Skin turgor refers to the skin's elasticity and hydration status. When a healthcare professional gently pinches the skin on the back of the patient's hand or forearm, dehydration is indicated by the skin not snapping back immediately. Monitoring blood pressure (choice B) is important but is more indicative of cardiovascular status rather than dehydration specifically. Checking for dry mucous membranes (choice C) can be a sign of dehydration, but skin turgor is a more direct assessment. Monitoring urine output (choice D) is also essential but may not provide immediate feedback on hydration status as skin turgor does.

2. What is the priority nursing action for a patient with shortness of breath?

• A. Administer oxygen
• B. Reposition the patient
• C. Check oxygen saturation
• D. Elevate the head of the bed

Correct answer: A

Rationale: Administering oxygen is the priority nursing action for a patient experiencing shortness of breath. Oxygen therapy aims to improve oxygenation levels quickly, addressing the underlying cause of the symptom. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in this scenario to ensure adequate oxygen supply to the body.

3. A client on glucocorticoid therapy is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I have my eyes examined annually.
• B. I take a calcium vitamin supplement daily.
• C. I limit my intake of foods with potassium.
• D. I consistently take my medication between 8 and 9 each evening.

Correct answer: B

Rationale: The correct answer is B. Taking a calcium supplement daily is crucial for clients on glucocorticoid therapy to prevent osteoporosis, a common side effect of long-term use. Choice A is unrelated to glucocorticoid therapy. Choice C, limiting potassium intake, is not necessary for clients on glucocorticoids. Choice D, taking medication consistently in the evening, is important but does not specifically address the side effects of glucocorticoid therapy.

4. A nurse is assessing a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 62/min
• B. Blood pressure of 118/78 mm Hg
• C. Respiratory rate of 10/min
• D. Pain rating of 4 on a scale of 0 to 10

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within normal limits and are not indicative of a potentially life-threatening complication associated with morphine therapy.

5. A nurse is assessing a client who has just returned from surgery and is experiencing acute pain. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Hypotension.
• C. Diaphoresis.
• D. Hyperactive bowel sounds.

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common response to acute pain due to increased sympathetic nervous system activity. Options A and B, Bradycardia and Hypotension, are unlikely findings in a client experiencing acute pain as pain usually triggers an increase in heart rate (tachycardia) and blood pressure. Option D, Hyperactive bowel sounds, is not typically associated with acute pain.

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