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. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse identify as a manifestation of digoxin toxicity?

• A. Constipation.
• B. Tachycardia.
• C. Visual disturbances.
• D. Hypertension.

Correct answer: C

Rationale: Visual disturbances, such as blurred or yellow vision, are common signs of digoxin toxicity. While constipation (Choice A) is not typically associated with digoxin toxicity, tachycardia (Choice B) and hypertension (Choice D) are not characteristic manifestations of digoxin toxicity. Therefore, the correct answer is visual disturbances (Choice C).

3. A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

• A. Glucose 180 mg/dL
• B. Sodium 136 mEq/L
• C. Potassium 3.8 mEq/L
• D. Albumin 3.5 g/dL

Correct answer: A

Rationale: The correct answer is A: "Glucose 180 mg/dL." Elevated glucose levels in a client receiving TPN may indicate hyperglycemia, which can lead to complications such as osmotic diuresis, dehydration, and electrolyte imbalances. It is essential to report this finding to the provider for further evaluation and management. Choices B, C, and D are within normal ranges and do not indicate immediate concerns related to TPN administration.

4. A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse report to the provider?

• A. Productive cough with green sputum
• B. Temperature of 37.1°C (98.8°F)
• C. Crackles in the lung bases
• D. Oxygen saturation of 95%

Correct answer: C

Rationale: In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, worsening of the condition, or development of complications such as pulmonary edema. This finding should be reported to the provider promptly for further evaluation and management. Choices A, B, and D are common in clients with pneumonia and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.

5. What is the priority intervention for a patient with a suspected pulmonary embolism?

• A. Administer oxygen
• B. Administer anticoagulants
• C. Prepare for surgery
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct answer is A: Administer oxygen. Administering oxygen is the priority intervention for a patient with a suspected pulmonary embolism to improve oxygenation levels. In pulmonary embolism, there is a blockage in one of the pulmonary arteries, leading to decreased oxygen exchange. Administering oxygen helps increase oxygen saturation levels. Anticoagulants (Choice B) are essential in the treatment of pulmonary embolism but are not the initial priority intervention. Surgery (Choice C) is not typically the first-line treatment for pulmonary embolism. Monitoring oxygen saturation (Choice D) is important but administering oxygen takes precedence as the immediate action to address hypoxemia.

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