F&E
A patient is admitted with a diagnosis of dehydration. Which of the following assessment findings would the nurse expect to see?
A) Increased urine output B) Bradycardia C) Hypertension D) Poor skin turgor
Answer: D
Rationale: Dehydration results from fluid intake or retention being less than the body's needs. Poor skin turgor (tenting) is a common sign of dehydration. Other signs include tachycardia and hypotension, as the body tries to compensate for the decreased fluid volume. Urine output would be decreased, not increased.
A nurse is assessing a client's sexual health history. Which of the following questions would be most appropriate to initiate the conversation?
A) "Do you have any sexual partners?"
B) "Are you sexually active?"
C) "Tell me about your sexual health and any concerns you might have."
D) "Have you been tested for sexually transmitted infections?"
Answer: C
Rationale: Option C is the most open-ended and client-centered approach. It invites the client to share what they feel is relevant and allows for a broader discussion of sexual health rather than focusing on specific behaviors or assumptions. Options A, B, and D are more direct and could make the client feel uncomfortable or judged.
A nurse is coordinating care for an elderly patient with multiple chronic conditions. Which of the following is a primary goal of care coordination?
A) Minimizing healthcare costs for the patient.
B) Ensuring the patient receives timely and appropriate care.
C) Reducing the workload of hospital staff.
D) Limiting the patient's interactions with specialists.
Answer: B) Ensuring the patient receives timely and appropriate care.
Rationale: Care coordination aims to ensure that patients receive the right care at the right time, improving health outcomes. While minimizing costs might be a secondary benefit, the primary goal is patient-centered care.
The nurse is caring for a patient with hyperkalemia. Which of the following findings on the ECG would suggest hyperkalemia?
A) Prolonged QT interval
B) Prominent U wave
C) Flattened T wave
D) Peaked T wave
Answer: D
Rationale: Hyperkalemia, an elevated potassium level, can lead to cardiac complications. A peaked T wave is a characteristic ECG finding in hyperkalemia. A prolonged QT interval is associated with hypocalcemia, and a prominent U wave and flattened T wave are associated with hypokalemia.
A client reports experiencing pain during intercourse. Which of the following factors could be contributing to this problem?
A) The client's age.
B) A history of sexually transmitted infections.
C) The client's nutritional status.
D) The general phases of sexual response.
Answer: B
Rationale: A history of sexually transmitted infections can lead to complications such as pelvic inflammatory disease, which can cause pain during intercourse. While age, nutritional status, and the general phases of sexual response can influence sexual health, they are less directly linked to causing pain during intercourse than a history of STIs.
The nurse is delegating tasks to a Licensed Practical Nurse (LPN). Which task is appropriate for the nurse to delegate to the LPN?
A) Developing a patient's plan of care.
B) Administering an intravenous push medication.
C) Monitoring a stable patient's vital signs.
D) Assessing a patient upon admission.
C) Monitoring a stable patient's vital signs.
Rationale: LPNs can perform tasks such as monitoring stable patient's vital signs. Developing a care plan and assessing a patient upon admission are typically RN responsibilities. Intravenous push medications are often outside the scope of LPN practice, depending on the jurisdiction.
An elderly patient is admitted with fluid volume excess. Which of the following nursing interventions is the priority?
A) Encouraging oral fluids
B) Monitoring for edema
C) Administering potassium supplements
D) Increasing sodium intake
Answer: B
Rationale: Fluid volume excess means that the body is retaining too much fluid. Elderly patients are at increased risk for fluid and electrolyte imbalances. Monitoring for edema is a priority in patients with fluid volume excess. Oral fluids would be restricted, not encouraged. Potassium supplements may or may not be needed, depending on electrolyte levels, but edema monitoring is more pressing. Sodium intake is usually restricted in fluid volume excess.
The nurse is providing education to an adolescent about contraception. Which statement indicates a need for further teaching?
A) "Contraception is a way to prevent pregnancy."
B) "Using condoms can help prevent sexually transmitted infections."
C) "All forms of contraception are 100% effective."
D) "It is important to discuss contraception with my partner."
Answer: C
Rationale: This question requires the test-taker to identify a false statement. Option C is incorrect; no form of contraception is 100% effective. The other statements are accurate.
A caregiver expresses feelings of being overwhelmed and constantly fatigued. Which of the following actions should the nurse prioritize?
A) Encourage the caregiver to seek respite care services.
B) Instruct the caregiver on how to administer complex medications.
C) Advise the caregiver to increase their working hours to afford help.
D) Reassure the caregiver that their feelings are normal and will pass.
Answer: A) Encourage the caregiver to seek respite care services.
Rationale: The nurse should recognize caregiver stress and intervene to support them. Respite care provides temporary relief for caregivers, addressing feelings of being overwhelmed and fatigued.
The nurse is reviewing the lab results of a patient with hypocalcemia. Which of the following signs and symptoms are consistent with this electrolyte imbalance?
A) Muscle spasms
B) Increased heart rate
C) Numbness and tingling
D) Lethargy
Answer: A, C
Rationale: Hypocalcemia (low calcium) can cause muscle spasms, numbness, and tingling. Hypercalcemia (high calcium) can cause increased heart rate (initially) and lethargy
Which of the following are considered risk factors for problems with sexuality? Select all that apply.
A) Chronic illness
B) Adolescence
C) Impaired nutrition
D) Medications
Answer: A, C, and D
Rationale: Chronic illness and medications can significantly impact sexual function and desire. Impaired nutrition can also affect overall health, including sexual health. While adolescence is a period of sexual development, it's more accurately described as a population at risk for problems with reproduction (e.g., unplanned pregnancy) rather than sexuality in general.
Which of the following are key attributes of effective care coordination? (Select all that apply)
A) Patient-centered approach
B) Limited communication
C) Timeliness
D) Teamwork
Answer: A, C, and D
Rationale: Effective care coordination involves a patient-centered approach, timeliness, and teamwork. Limited communication is contrary to effective care coordination, as communication is important in care coordination.
A patient is receiving intravenous fluids. Which statements correctly describe the properties of intravenous solutions?
A) Hypotonic solutions cause fluid to move out of the blood vessels into the cells.
B) Isotonic solutions cause cells to shrink.
C) Hypertonic solutions draw fluid into the blood vessels from the cells.
D) Colloid solutions are thin and move easily across membranes.
Answer: A, C
Rationale: Hypotonic solutions move fluid out of the vessels into the cells. Isotonic solutions “stay where I put it” and do not cause shrinking or swelling of cells. Hypertonic solutions draw fluid into the vessels. Crystalloid solutions are thin and move across membranes; colloid solutions contain larger molecules (like albumin) and stay in the vessels.
Which of the following factors can influence an individual's sexuality? Select all that apply.
A) Cultural factors
B) Biological factors
C) Legal factors
D) Spiritual factors
Answer: A, B, C, and D
Rationale: Sexuality is a complex concept influenced by a multitude of factors. Cultural, biological, legal, and spiritual factors all play a role in shaping an individual's understanding, experience, and expression of sexuality.
Which of the following are responsibilities of the registered nurse (RN) in the delegation process? (Select all that apply)
A) Ensuring the task is within the delegatee's scope of practice
B) Providing clear instructions for the task
C) Supervising the delegatee to ensure proper completion of the task
D) Assuming full responsibility for the delegatee's actions
Answer: A, B, and C
Rationale: The RN is responsible for ensuring the task is within the delegatee's scope, providing clear instructions, and supervising the delegatee. The RN is accountable for the delegation, but not fully responsible for the delegatee's actions, provided the delegation was appropriate.