Nursing Elites

1. How should signs of dehydration in an elderly patient be assessed?

• A. Monitor skin turgor
• B. Check for dry mucous membranes
• C. Monitor for sunken eyes
• D. Check capillary refill

Correct answer: A

Rationale: Corrected Rationale: Monitoring skin turgor is a reliable method to assess dehydration in elderly patients. Skin turgor refers to the skin's elasticity or the skin's ability to return to its normal position after being pinched. In dehydration, the skin loses its elasticity, becoming less flexible and slower to return to its original state. Checking for dry mucous membranes (Choice B), monitoring for sunken eyes (Choice C), and checking capillary refill (Choice D) are all relevant assessments in dehydration but are not as specific or sensitive as monitoring skin turgor. Dry mucous membranes and sunken eyes are indicators of dehydration, while capillary refill is more related to circulatory status and less specific to dehydration.

2. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client's contractions are occurring every 45 seconds with a nine-second duration, and the fetal heart rate is 170 to 180 beats per minute. Which of the following actions should the nurse take?

• A. Discontinue oxytocin infusion
• B. Increase oxytocin infusion
• C. Decrease oxytocin infusion
• D. Maintain oxytocin infusion

Correct answer: A

Rationale: In this scenario, the client is experiencing frequent contractions with a short duration and an elevated fetal heart rate, indicating potential fetal distress. Discontinuing the oxytocin infusion is crucial to prevent further complications and restore normal fetal parameters. Increasing or maintaining the oxytocin infusion could exacerbate the situation, leading to more distress for the fetus. Decreasing the oxytocin infusion may not be sufficient to address the current issue and could delay the improvement of fetal well-being.

3. A client with bipolar disorder and experiencing mania is under the care of a nurse. Which intervention should the nurse include in the plan?

• A. Encourage the client to spend time in the day room.
• B. Withdraw the client's TV privileges if they do not attend group therapy.
• C. Encourage the client to take frequent rest periods.
• D. Place the client in seclusion when they exhibit signs of anxiety.

Correct answer: C

Rationale: Encouraging the client to take frequent rest periods is an appropriate intervention for managing mania in a client with bipolar disorder. During a manic episode, individuals often have increased energy levels, decreased need for sleep, and may engage in high-risk behaviors. Encouraging regular rest periods can help reduce stimulation and promote relaxation, which may assist in stabilizing mood. Choices A and B are not as effective in managing manic symptoms, as they do not directly address the client's need for rest and relaxation. Choice D is inappropriate because placing the client in seclusion can increase feelings of anxiety and agitation, worsening the manic episode.

4. A client who has a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following statements should the nurse include?

• A. Use lotion on your feet to prevent dry, cracked skin, avoiding application between the toes.
• B. Avoid soaking your feet in warm water daily to prevent dry skin.
• C. Trim your toenails straight across to prevent injury.
• D. Do not apply a heating pad to your feet if they feel cold.

Correct answer: C

Rationale: The correct answer is C. Trimming toenails straight across is essential for clients with diabetes to prevent the risk of ingrown toenails and injury. Using lotion on feet can be beneficial but should not be applied between the toes to avoid moisture buildup, which can lead to infections. Soaking feet in warm water can lead to dry skin, increasing the risk of cracks and other complications. Applying a heating pad to feet when they feel cold is not recommended for clients with diabetes due to impaired sensation, which can result in burns and other injuries.

5. When caring for a client with a new prescription for enoxaparin for the prevention of DVT, what is an appropriate action by the nurse?

• A. Expel any air bubbles at the top of the prefilled syringe
• B. Massage the injection site to evenly distribute the medication
• C. Inject the medication into the lateral abdominal wall
• D. Administer an NSAID for injection site discomfort

Correct answer: C

Rationale: When administering enoxaparin for the prevention of DVT, the nurse should inject the medication into the lateral abdominal wall. This site is preferred for subcutaneous injections of enoxaparin to reduce the risk of bleeding or injury. Expelling air bubbles, massaging the injection site, or administering an NSAID for discomfort are not appropriate actions and could lead to complications or ineffective medication delivery.

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