Nursing Elites

1. The nurse and an unlicensed nursing assistant are caring for a group of clients. Which nursing intervention should the nurse perform?

• A. Measure the client's output from the indwelling catheter.
• B. Record the client's intake and output on the I & O sheet.
• C. Instruct the client on appropriate fluid restrictions.
• D. Provide water for a client diagnosed with diabetes insipidus.

Correct answer: C

Rationale: Instructing the client on appropriate fluid restrictions is a nursing intervention that requires professional judgment and should be performed by the nurse. In this scenario, the nurse should provide education regarding fluid restrictions based on the client's individual needs. Measuring the client's output from the indwelling catheter (choice A) and recording intake and output (choice B) can be tasks delegated to the unlicensed nursing assistant. Providing water for a client diagnosed with diabetes insipidus (choice D) is not appropriate as these clients often require careful fluid management to prevent complications.

2. Which of the following ethical principles is demonstrated when a nurse provides truthful information to a patient?

• A. Veracity
• B. Autonomy
• C. Justice
• D. Nonmaleficence

Correct answer: A

Rationale: The correct answer is A: Veracity. Veracity is the ethical principle of truthfulness and honesty in communication. When a nurse provides truthful information to a patient, it demonstrates integrity and respect for the patient's right to know the truth about their health condition and treatment. Choice B, Autonomy, refers to respecting the patient's right to make their own decisions. Choice C, Justice, involves fairness and equality in healthcare decisions. Choice D, Nonmaleficence, relates to the obligation to do no harm and prevent harm to the patient.

3. A healthcare professional is reading a physician's progress notes in the client's record and reads that the physician has documented 'insensible fluid loss of approximately 800 mL daily.' The healthcare professional understands that this type of fluid loss can occur through:

• A. The skin
• B. Urinary output
• C. Wound drainage
• D. The gastrointestinal tract

Correct answer: A

Rationale: Insensible fluid loss refers to the fluid lost from the body that is not easily measured, such as through sweating and respiration. The skin is a major contributor to insensible fluid loss due to evaporation of water through the skin. Choice B, urinary output, represents measurable fluid loss through urine excretion. Choice C, wound drainage, is a measurable form of fluid loss that occurs externally from a wound. Choice D, the gastrointestinal tract, primarily involves fluid loss through feces and is also a measurable form of output. Therefore, the correct answer is 'A: The skin,' as it is the main route for insensible fluid loss.

4. The client with DM is being taught about the signs of hyperglycemia. Which symptom should the nurse include?

• A. Excessive thirst
• B. Sweating
• C. Shaking
• D. Hunger

Correct answer: A

Rationale: Excessive thirst, also known as polydipsia, is a hallmark symptom of hyperglycemia. When blood glucose levels are high, the body tries to eliminate the excess glucose through urine, leading to increased urination and subsequent thirst. Sweating, shaking, and hunger are more commonly associated with hypoglycemia, not hyperglycemia. Sweating can occur when blood sugar levels drop too low, shaking is a sign of hypoglycemia, and hunger is often a result of low blood sugar levels triggering the body to seek fuel.

5. A client with DM is taking regular and NPH insulin every morning. The nurse should provide which instruction to the client?

• A. Take the regular insulin first, then the NPH insulin.
• B. Take the NPH insulin first, then the regular insulin.
• C. Mix the insulins in a separate syringe.
• D. Take the regular insulin first and immediately follow it with the NPH insulin.

Correct answer: A

Rationale: The correct instruction for the client is to take the regular insulin first, then the NPH insulin. Regular insulin should be administered before NPH insulin to prevent contamination and maintain the potency of each insulin type. Choice B is incorrect because NPH insulin should not be taken before regular insulin. Mixing the insulins in a separate syringe, as suggested in choice C, is not recommended as it may alter the effectiveness of the insulins. Choice D is also incorrect as taking the regular insulin first and immediately following it with NPH insulin is not the recommended administration sequence.

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