Nursing Elites

1. A client presents with severe dehydration due to prolonged vomiting. What is the nurse's priority intervention?

• A. Encourage the client to drink clear fluids.
• B. Assess the client's skin turgor and mucous membranes.
• C. Monitor the client's vital signs frequently.
• D. Administer an antiemetic as prescribed.

Correct answer: B

Rationale: The correct answer is to assess the client's skin turgor and mucous membranes. When a client presents with severe dehydration, assessing skin turgor (elasticity of the skin) and mucous membranes (such as checking for dryness in the mouth) is crucial in determining the extent of dehydration. Encouraging the client to drink clear fluids (Choice A) may be important but assessing dehydration severity takes precedence. Monitoring vital signs (Choice C) is essential but assessing dehydration status comes first. Administering an antiemetic (Choice D) addresses vomiting but does not directly assess dehydration.

2. A client with chronic obstructive pulmonary disease (COPD) is receiving supplemental oxygen. The client reports feeling short of breath and has a respiratory rate of 28 breaths per minute. What should the nurse do first?

• A. Increase the oxygen flow rate
• B. Notify the healthcare provider
• C. Administer a bronchodilator
• D. Elevate the head of the bed

Correct answer: D

Rationale: Elevating the head of the bed promotes lung expansion and improves oxygenation, making it the priority intervention for a client with shortness of breath. This position helps in maximizing lung expansion and aiding ventilation-perfusion matching in patients with COPD. Increasing the oxygen flow rate may be necessary but should come after optimizing the client's positioning. Notifying the healthcare provider and administering a bronchodilator are not the initial interventions for addressing shortness of breath in a client with COPD.

3. A client with type 1 diabetes is admitted to the emergency room with abdominal pain, polyuria, and confusion. What should the nurse implement first?

• A. Administer intravenous insulin.
• B. Start an intravenous fluid bolus.
• C. Obtain a blood glucose level.
• D. Administer an antiemetic.

Correct answer: B

Rationale: In this scenario, the nurse should first start an intravenous fluid bolus. This intervention is crucial in addressing severe dehydration associated with diabetic ketoacidosis, a life-threatening complication of type 1 diabetes. Administering intravenous insulin (Choice A) is important but should follow fluid resuscitation. Obtaining a blood glucose level (Choice C) is necessary but not as urgent as addressing the dehydration. Administering an antiemetic (Choice D) is not the priority in this situation.

4. The nurse is providing teaching to a client with gastroesophageal reflux disease (GERD). Which instruction should the nurse include?

• A. Eat large meals to decrease acid production
• B. Avoid lying down immediately after eating
• C. Limit fluid intake with meals
• D. Drink carbonated beverages to aid digestion

Correct answer: B

Rationale: The correct instruction for a client with GERD is to avoid lying down immediately after eating. This helps prevent stomach acid from flowing back into the esophagus, which can worsen symptoms. Eating large meals can actually increase acid production and exacerbate GERD. Limiting fluid intake with meals may be beneficial for some individuals, but it is not a key instruction for managing GERD. Drinking carbonated beverages can trigger reflux symptoms and should be avoided by individuals with GERD.

5. A client is admitted with a suspected bowel obstruction. What assessment finding should the nurse report immediately?

• A. Absent bowel sounds in all quadrants.
• B. Distended abdomen with a firm, rigid feel.
• C. Frequent episodes of nausea and vomiting.
• D. Hyperactive bowel sounds and abdominal cramping.

Correct answer: B

Rationale: A distended abdomen with a firm, rigid feel is a concerning sign that suggests a complication such as bowel perforation, which requires immediate intervention. Absent bowel sounds can be expected in bowel obstructions but are not as urgent as a rigid abdomen. Frequent episodes of nausea and vomiting are common with bowel obstructions but do not indicate an immediate life-threatening complication. Hyperactive bowel sounds and abdominal cramping are more indicative of bowel obstruction rather than a complication requiring immediate attention.

Similar Questions