Nursing Elites

1. The healthcare provider is caring for a client with severe anemia. Which assessment finding requires immediate intervention?

• A. Pale skin
• B. Increased heart rate
• C. Shortness of breath
• D. Fatigue

Correct answer: C

Rationale: Shortness of breath is a critical sign in severe anemia as it indicates inadequate oxygenation, which can be life-threatening. Immediate intervention is necessary to address this condition. Pale skin (choice A) is a common finding in anemia but not as urgent as shortness of breath. Increased heart rate (choice B) is a compensatory mechanism in anemia to maintain oxygen delivery and is important but not as urgent as addressing inadequate oxygenation. Fatigue (choice D) is a common symptom in anemia but does not indicate an immediate life-threatening situation like shortness of breath does.

2. The nurse leading a medical-surgical unit care team assigns client care to a PN and a UAP. Which task should the nurse delegate to the UAP?

• A. Assess a client's pain level post-surgery
• B. Turn and reposition a client with a total hip replacement
• C. Administer a dose of insulin per sliding scale
• D. Change a postoperative dressing

Correct answer: B

Rationale: Turning and repositioning a client is within the scope of practice of a UAP. This task helps prevent pressure ulcers and assists in maintaining the client's comfort and mobility. Assessing pain level post-surgery requires clinical judgment and interpretation, making it appropriate for a PN or RN. Administering medication like insulin involves critical thinking and potential adjustments based on the client's condition, which is the responsibility of a licensed nurse. Changing postoperative dressings involves wound assessment, infection control, and knowledge of aseptic techniques, tasks that fall under the purview of a PN or RN.

3. The nurse is providing discharge teaching to a client with newly diagnosed hypertension. Which lifestyle modification should the nurse emphasize to the client?

• A. Increase sodium intake to improve fluid balance
• B. Engage in regular physical activity
• C. Increase caffeine intake to improve energy
• D. Reduce potassium intake to lower blood pressure

Correct answer: B

Rationale: Engaging in regular physical activity is a crucial lifestyle modification for managing hypertension. Regular exercise helps improve cardiovascular health, lower blood pressure, and contribute to overall well-being. Choices A, C, and D are incorrect. Increasing sodium intake is not recommended for hypertension as it can worsen fluid retention and elevate blood pressure. Increasing caffeine intake is also not advised as it may lead to increased heart rate and blood pressure. Reducing potassium intake is not beneficial as potassium is essential for maintaining healthy blood pressure levels.

4. A client with severe dehydration is admitted to the hospital. Which assessment finding indicates that the client's condition is improving?

• A. The client reports feeling less thirsty
• B. Urine output increases to 40 mL/hour
• C. Heart rate decreases from 120 to 110 beats per minute
• D. Skin turgor returns to normal

Correct answer: B

Rationale: An increase in urine output is a reliable indicator that the client's hydration status is improving. This reflects adequate fluid replacement and improved kidney function. Choice A is subjective and may not always indicate improved hydration. Choice C, while a positive sign, may be influenced by other factors such as medications or pain. Choice D, skin turgor returning to normal, is a delayed indicator of hydration status and may take time to improve even after hydration is initiated.

5. A client receiving full-strength continuous enteral tube feeding develops diarrhea. What intervention should the nurse take?

• A. Stop the feeding and provide IV fluids.
• B. Dilute the feeding to half strength and continue at the same rate.
• C. Reduce the feeding rate and monitor for improvement.
• D. Add fiber to the client's diet to resolve diarrhea.

Correct answer: B

Rationale: When a client develops diarrhea from continuous enteral tube feeding, diluting the feeding to half strength and continuing at the same rate is the appropriate intervention. This helps reduce the strength of the feeding, minimizing gastrointestinal upset while still providing necessary nutrition. Stopping the feeding abruptly (Choice A) may lead to nutritional deficits. Simply reducing the feeding rate (Choice C) may not effectively address the issue of diarrhea. Adding fiber (Choice D) could potentially worsen the diarrhea in this scenario instead of resolving it.

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