Nursing Elites

1. What is the priority nursing action for a dehydrated client who needs fluids?

• A. Administer antiemetics to prevent vomiting
• B. Monitor electrolyte levels frequently
• C. Administer oral rehydration solutions
• D. Insert an NG tube for fluid administration

Correct answer: B

Rationale: The correct answer is to monitor electrolyte levels frequently. When a client is dehydrated and needs fluids, it is essential to monitor electrolyte levels to prevent complications such as electrolyte imbalances. Administering antiemetics to prevent vomiting (Choice A) may be necessary but is not the priority when addressing dehydration. Administering oral rehydration solutions (Choice C) can be beneficial, but monitoring electrolyte levels takes precedence to ensure proper hydration. Inserting an NG tube for fluid administration (Choice D) is invasive and not typically the first-line approach for managing dehydration.

2. A client has developed phlebitis at the IV site. What should the nurse do first?

• A. Apply a warm compress to the IV site
• B. Discontinue the IV and notify the provider
• C. Monitor the IV site for signs of infection
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the priority action for the nurse is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and removing the IV can help prevent further complications. Applying a warm compress may provide symptomatic relief but does not address the root cause. Monitoring for infection is important, but immediate action to remove the source of inflammation is crucial. Administering an anti-inflammatory medication is not the first-line intervention for phlebitis; removal of the IV is necessary.

3. What are the signs of hypoglycemia, and how should they be managed?

• A. Sweating, trembling; administer glucose
• B. Headache, confusion; administer insulin
• C. Dizziness, fatigue; administer glucose
• D. Increased heart rate; provide a high-sugar snack

Correct answer: A

Rationale: The correct signs of hypoglycemia are sweating and trembling. These should be managed by administering glucose to raise blood sugar levels. Headache, confusion, dizziness, fatigue, or increased heart rate are not typical signs of hypoglycemia. Administering insulin in response to hypoglycemia would further lower blood sugar levels, exacerbating the condition.

4. How should a healthcare professional assess and manage a patient with delirium?

• A. Assess for confusion and reorient the patient
• B. Provide a quiet environment and administer sedatives
• C. Provide oxygen therapy and monitor vital signs
• D. Provide pain relief and monitor for signs of recovery

Correct answer: A

Rationale: The correct way to assess and manage a patient with delirium is by assessing for confusion and reorienting the patient. Delirium is characterized by acute confusion and disturbance in attention, so reorienting the patient to time, place, and person can help improve their awareness and cognition. Providing a quiet environment is important to reduce stimuli that can exacerbate delirium, but administering sedatives may worsen the condition. Oxygen therapy and monitoring vital signs are essential aspects of general patient care but are not specific to managing delirium. Providing pain relief is important for overall patient comfort but may not directly address the core issue of delirium.

5. What are the key signs of hyperglycemia?

• A. Increased thirst and frequent urination
• B. Decreased appetite and low blood pressure
• C. Weight loss and nausea
• D. Increased sweating and confusion

Correct answer: A

Rationale: The correct answer is A: Increased thirst and frequent urination. These are classic signs of hyperglycemia, indicating elevated blood sugar levels. Choice B is incorrect as hyperglycemia usually presents with increased appetite rather than decreased appetite and low blood pressure. Choice C is incorrect as weight loss is more commonly associated with uncontrolled diabetes rather than hyperglycemia. Choice D is incorrect as increased sweating and confusion are not typical signs of hyperglycemia.

Similar Questions