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 client who has a positive stool culture for Clostridium difficile should be placed in which type of room for infection control purposes?

• A. Wear a face shield prior to entering the room.
• B. Place the client in a private room.
• C. Place the client in a negative pressure room.
• D. Use an alcohol-based hand rub following client care.

Correct answer: B

Rationale: Placing the client in a private room is the appropriate infection control measure for C. difficile to prevent the spread of infection. While wearing a face shield may be necessary for procedures that generate splashes or sprays, it is not the primary precaution for C. difficile. Negative pressure rooms are typically used for airborne infections, not for C. difficile. Using an alcohol-based hand rub is important for hand hygiene but is not specific to managing C. difficile infection.

3. A client with diabetes mellitus is being taught by a nurse about managing blood glucose levels. Which of the following client statements indicates an understanding of the teaching?

• A. I will eat a snack if my blood glucose level is below 70 mg/dL.
• B. I will take my insulin if my blood glucose level is above 200 mg/dL.
• C. I will check my blood glucose level once a week.
• D. I will take my insulin only when I feel symptoms of hyperglycemia.

Correct answer: A

Rationale: Choice A is the correct answer because consuming a snack when the blood glucose level is below 70 mg/dL helps prevent hypoglycemia in clients with diabetes mellitus. Choice B is incorrect because taking insulin when blood glucose is high (above 200 mg/dL) helps manage hyperglycemia, not hypoglycemia. Choice C is incorrect as checking blood glucose levels once a week is insufficient for proper diabetes management, which typically requires more frequent monitoring. Choice D is incorrect because waiting for symptoms of hyperglycemia to take insulin can lead to uncontrolled blood glucose levels.

4. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?

• A. Vomiting.
• B. Hypertension.
• C. Epigastric pain.
• D. Contractions.

Correct answer: D

Rationale: Following an amniocentesis at 33 weeks of gestation, the nurse should monitor the client for contractions. Contractions can indicate preterm labor, which requires immediate attention. Vomiting, hypertension, and epigastric pain are not typically associated with amniocentesis complications at this gestational age.

5. A client is postoperative following a hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?

• A. Encourage the client to lie flat in bed.
• B. Apply heat to the incision site.
• C. Use an abduction pillow between the client's legs.
• D. Place a trochanter roll under the client's knees.

Correct answer: C

Rationale: Using an abduction pillow between the client's legs is essential in maintaining proper alignment and preventing dislocation of the hip joint following a hip arthroplasty. Encouraging the client to lie flat in bed (Choice A) is not recommended as early mobilization is crucial for preventing complications. Applying heat to the incision site (Choice B) is not typically done immediately postoperatively. Placing a trochanter roll under the client's knees (Choice D) is not as beneficial as using an abduction pillow to maintain proper positioning.

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