Nursing Elites

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

• A. Monitor skin turgor and check urine output
• B. Assess for jugular venous distention
• C. Auscultate lung sounds and monitor for fever
• D. Monitor for cyanosis and increased respiratory rate

Correct answer: A

Rationale: Correct Answer: When assessing a patient for dehydration, healthcare professionals should monitor skin turgor, as it indicates the degree of dehydration, and check urine output, as decreased urine output can be a sign of dehydration. Choices B, C, and D are incorrect because they do not directly assess for dehydration. Assessing for jugular venous distention (B) is more relevant for heart failure, auscultating lung sounds and monitoring for fever (C) are more relevant for respiratory infections, and monitoring for cyanosis and increased respiratory rate (D) are more indicative of respiratory distress rather than dehydration.

2. The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see first?

• A. A 12-year-old oozing blood from a laceration on the left thumb due to a cut from a rusty metal can
• B. A 19-year-old with a fever of 103.8°F who is able to identify her sister but not the place and time
• C. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain
• D. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL

Correct answer: B

Rationale: The correct answer is B. A 19-year-old with a fever of 103.8°F who is confused and unable to orient to place and time likely has a severe infection or a serious medical condition affecting the central nervous system. This client needs immediate attention as altered mental status combined with a high fever can indicate a life-threatening situation. Choices A, C, and D present important conditions that require medical care, but they are not as urgent as the 19-year-old with a high fever and confusion. The 12-year-old with a laceration may require treatment for bleeding and a tetanus shot, the 49-year-old with a compound fracture needs urgent orthopedic intervention, and the 65-year-old with a high blood sugar is concerning for hyperglycemia but can wait momentarily compared to the client with a fever and altered mental status.

3. During the admission of a client with a latex allergy, which of the following supplies has the potential to contain latex?

• A. Urinary catheters
• B. Indwelling catheters
• C. Sterile gloves
• D. Sterile gowns

Correct answer: A

Rationale: The correct answer is A: Urinary catheters. Urinary catheters often contain latex, which can trigger an allergic reaction in clients with latex allergy. Indwelling catheters (choice B), sterile gloves (choice C), and sterile gowns (choice D) can be latex-free alternatives. However, urinary catheters are more commonly made with latex, making them a higher risk for clients with latex allergies.

4. What is the proper technique for measuring blood pressure manually?

• A. Use a stethoscope to listen for the Korotkoff sounds
• B. Ensure the patient is seated with the arm supported
• C. Use a manual sphygmomanometer
• D. Deflate the cuff slowly while listening to the heartbeat

Correct answer: A

Rationale: The correct technique for measuring blood pressure manually involves using a stethoscope to listen for the Korotkoff sounds. Choice B, ensuring the patient is seated with the arm supported, is important but not the specific technique for measuring blood pressure. Choice C, using a manual sphygmomanometer, is a necessary tool but not the technique itself. Choice D, deflating the cuff slowly while listening to the heartbeat, is not the correct technique as the deflation should be done while listening for the Korotkoff sounds to determine the systolic and diastolic blood pressure readings.

5. A client with COPD is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?

• A. Administer oxygen at 2 L/min via nasal cannula
• B. Encourage pursed-lip breathing
• C. Position the client in high Fowler's position
• D. Encourage deep breathing and coughing

Correct answer: B

Rationale: The correct intervention for a client with COPD is to encourage pursed-lip breathing. Pursed-lip breathing helps maintain airway patency by preventing the collapse of small airways during exhalation, improving breathing efficiency. Administering oxygen at 2 L/min via nasal cannula may be appropriate for some COPD patients but is not the priority intervention. Positioning the client in high Fowler's position may help improve breathing but is not as specific as pursed-lip breathing for COPD. Encouraging deep breathing and coughing may be beneficial in other respiratory conditions, but it is not the most effective intervention for COPD.

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