Nursing Elites

1. What are the clinical manifestations of hypovolemic shock, and how should a nurse respond?

• A. Hypertension, bradycardia, and oliguria
• B. Bradycardia, hypertension, and peripheral edema
• C. Tachypnea, cool skin, and confusion
• D. Tachycardia, hypotension, and decreased urine output

Correct answer: D

Rationale: The correct answer is D: Tachycardia, hypotension, and decreased urine output are classic clinical manifestations of hypovolemic shock. In hypovolemic shock, the body tries to compensate for low blood volume by increasing the heart rate (tachycardia) to maintain cardiac output, leading to hypotension and decreased urine output. Prompt fluid replacement is necessary to restore intravascular volume. Choices A, B, and C are incorrect because they do not represent the typical manifestations of hypovolemic shock.

2. A nurse manager is planning client assignments for the day. Which client should the nurse assign to the nursing assistant?

• A. A client who needs help ambulating.
• B. A client who requires complex wound care.
• C. A client who needs intravenous antibiotics.
• D. A client who is NPO and requires IV hydration.

Correct answer: A

Rationale: The correct answer is A because ambulating a client is a non-invasive task that can be safely and effectively performed by a nursing assistant. Choice B is incorrect as complex wound care requires specialized skills usually performed by licensed nurses. Choice C involves administering intravenous antibiotics, which also requires a higher level of training and assessment skills than a nursing assistant possesses. Choice D, involving a client who is NPO and requires IV hydration, may involve further assessments and monitoring that are beyond the scope of a nursing assistant.

3. A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin IV every 8 hours. Which of the following serum laboratory results should the nurse report to the provider before administering the gentamicin?

• A. Hematocrit 45%
• B. Sodium 140 mEq/L
• C. Creatinine 2.4 mg/dL
• D. Potassium 4.0 mEq/L

Correct answer: C

Rationale: An elevated creatinine level indicates potential kidney dysfunction, which is crucial when administering gentamicin as it can be nephrotoxic. Reporting a high creatinine level to the provider is essential to prevent further kidney damage. Choice A (Hematocrit 45%) is within the normal range and not directly related to gentamicin administration. Choice B (Sodium 140 mEq/L) and Choice D (Potassium 4.0 mEq/L) are also within normal limits and do not directly impact the administration of gentamicin.

4. What is the primary goal when caring for a patient with chronic obstructive pulmonary disease (COPD)?

• A. Maintain the patient's oxygen saturation above 90%.
• B. Administer bronchodilators as prescribed.
• C. Improve the patient's nutritional intake.
• D. Encourage the patient to limit physical activity.

Correct answer: A

Rationale: The correct answer is to maintain the patient's oxygen saturation above 90% when caring for a patient with COPD. In COPD, impaired gas exchange leads to decreased oxygen levels in the blood. By ensuring oxygen saturation remains above 90%, healthcare providers can prevent hypoxia and its complications. Administering bronchodilators as prescribed (Choice B) is an important intervention in managing COPD symptoms, but it is not the primary goal. Improving the patient's nutritional intake (Choice C) and encouraging the patient to limit physical activity (Choice D) are also essential aspects of COPD management, but they are not the primary goal when caring for a patient with this condition.

5. A nurse is teaching a client who has a new prescription for digoxin. Which of the following adverse effects should the nurse instruct the client to monitor and report to the provider?

• A. Increased appetite
• B. Rash on the face
• C. Yellow-tinged vision
• D. Weight gain

Correct answer: C

Rationale: The correct answer is C: 'Yellow-tinged vision.' Yellow-tinged vision is a characteristic sign of digoxin toxicity, indicating an overdose of the medication. This visual disturbance is a critical adverse effect that should be reported promptly to the healthcare provider to prevent serious complications.\n\nChoice A, 'Increased appetite,' is not typically associated with digoxin use and is not a common adverse effect.\n\nChoice B, 'Rash on the face,' is also not a common adverse effect of digoxin. Skin rash is not a typical manifestation of digoxin toxicity.\n\nChoice D, 'Weight gain,' is not a common adverse effect of digoxin. Weight gain is not a typical symptom of digoxin toxicity and is unlikely to be related to the medication.

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