Nursing Elites

1. In which position will you place your patient when they are demonstrating the signs and symptoms of hypovolemic shock?

• A. The Trendelenburg position
• B. The supine position
• C. The left lateral position
• D. The right lateral position

Correct answer: A

Rationale: The correct answer is A, the Trendelenburg position. This position involves placing the patient with their legs elevated higher than their head. It is used to increase blood flow to the upper body, including the brain and heart, in cases of hypovolemic shock. This helps improve perfusion to vital organs. Choices B, C, and D are incorrect as they do not facilitate the desired redistribution of blood flow needed in hypovolemic shock. The supine position is lying flat on the back, the left lateral position is lying on the left side, and the right lateral position is lying on the right side.

2. A nurse in the emergency department is performing triage for a group of clients who were in a train crash. Which of the following clients should the nurse tag as emergent?

• A. A client who has an open fracture of the femur
• B. A client who has periorbital ecchymosis
• C. A client who has asymmetrical thorax
• D. A client who has a deep-partial thickness burn on the lower extremities

Correct answer: C

Rationale: In a triage situation, an asymmetrical thorax suggests a potentially life-threatening condition such as a pneumothorax or hemothorax, requiring immediate attention. This client should be tagged as emergent. Periorbital ecchymosis and deep-partial thickness burns, while concerning, may not indicate an immediate life-threatening situation. An open fracture of the femur, although serious, can be prioritized after addressing emergent cases.

3. A client diagnosed with type 1 diabetes receives insulin. He asks the nurse why he can't just take pills instead. What is the best response by the nurse?

• A. Insulin must be injected because it needs to work quickly.
• B. Insulin can't be in a pill because it is destroyed in stomach acid.
• C. Have you talked to your doctor about taking pills instead?
• D. I know it is tough, but you will get used to the shots soon.

Correct answer: B

Rationale: The correct answer is B because insulin cannot be taken orally as it gets destroyed by stomach acid. Choice A is incorrect as the speed of action is not the reason why insulin can't be in pill form. Choice C is incorrect as it doesn't address the nature of insulin. Choice D is incorrect as it doesn't provide a factual reason why insulin can't be in pill form.

4. A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?

• A. Apply vest restraints to residents who are confused
• B. Keep all four side rails up on beds at night
• C. Accompany residents over 85 years of age during ambulation
• D. Implement rounds every 2 hours during the day to offer toileting

Correct answer: D

Rationale: The correct answer is to implement rounds every 2 hours during the day to offer toileting. This intervention helps prevent falls by addressing the common cause of unassisted mobility, which is the need to use the bathroom. Choice A is incorrect as restraints should not be the first choice for fall prevention due to the risk of injury and loss of independence. Choice B is incorrect because all side rails up can lead to entrapment and should only be used based on individualized assessments. Choice C may not be feasible for all residents over 85 years old and does not directly address the risk of falls.

5. Ben injects his insulin as prescribed, but then gets busy and forgets to eat. What will the best assessment of the nurse reveal?

• A. The client will be very thirsty.
• B. The client will complain of nausea.
• C. The client will need to urinate.
• D. The client will have moist skin.

Correct answer: D

Rationale: The correct answer is D. In this scenario, since Ben took his insulin but forgot to eat, he is at risk of developing hypoglycemia. Moist skin is a sign of hypoglycemia, which can occur when blood sugar levels drop too low. Thirstiness (choice A) is more commonly associated with hyperglycemia (high blood sugar levels). Nausea (choice B) and frequent urination (choice C) are not typical immediate signs of hypoglycemia caused by missing a meal after insulin administration.

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