Nursing Elites

1. A healthcare provider is caring for a client who has a leg fracture and reports severe pain. Which of the following actions should the healthcare provider take first?

• A. Administer pain medication
• B. Reposition the client's leg
• C. Elevate the client's leg
• D. Check the client's neurovascular status

Correct answer: D

Rationale: Checking the client's neurovascular status is the priority when caring for a client with severe pain after a leg fracture. This assessment is crucial to identify any signs of vascular compromise or nerve damage, such as compartment syndrome. Administering pain medication can help alleviate the pain but should only be done after ensuring the client's neurovascular status is stable. Repositioning or elevating the leg may worsen the condition if there are underlying vascular issues, making these options lower in priority than assessing neurovascular status.

2. A client with IV fluids has developed redness and warmth at the IV site. What is the next step the nurse should take?

• A. Apply a cold compress to the IV site
• B. Discontinue the IV and notify the healthcare provider
• C. Monitor the IV site for signs of infection
• D. Increase the IV flow rate to improve circulation

Correct answer: B

Rationale: When a client develops redness and warmth at the IV site, it is indicative of phlebitis, which is inflammation of the vein. The next step for the nurse should be to discontinue the IV and notify the healthcare provider. Applying a cold compress may provide temporary relief but does not address the underlying issue. Monitoring for infection is important, but in this case, the presence of redness and warmth suggests phlebitis, not infection. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.

3. What is the priority for a client with dehydration?

• A. Administer antiemetics to prevent nausea
• B. Monitor electrolyte levels to prevent imbalances
• C. Administer oral rehydration solutions
• D. Administer intravenous fluids

Correct answer: B

Rationale: The priority for a client with dehydration is to monitor electrolyte levels to prevent imbalances. Dehydration can lead to electrolyte disturbances, which can have serious consequences. Administering antiemetics (Choice A) may help with nausea but does not address the root cause of dehydration. Administering oral rehydration solutions (Choice C) can be beneficial, but monitoring electrolyte levels is crucial in managing dehydration. Administering intravenous fluids (Choice D) is important in severe cases of dehydration, but monitoring electrolytes should come first to assess the extent of the imbalance and guide fluid replacement therapy effectively.

4. How should a healthcare professional manage a patient with a suspected stroke?

• A. Monitor for changes in neurological status and administer thrombolytics
• B. Monitor for speech difficulties and administer oxygen
• C. Provide IV fluids and monitor blood pressure
• D. Administer pain relief and monitor for respiratory failure

Correct answer: A

Rationale: Corrected Rationale: When managing a patient with a suspected stroke, it is crucial to monitor for changes in neurological status as this can provide important information about the patient's condition. Administering thrombolytics, if indicated, is a critical intervention in the acute phase of an ischemic stroke to help dissolve blood clots and restore blood flow to the brain. This choice is the correct answer because it addresses the immediate management needs of a patient with a suspected stroke. Choices B, C, and D are incorrect because while monitoring for speech difficulties, administering oxygen, providing IV fluids, monitoring blood pressure, administering pain relief, and monitoring for respiratory failure are important aspects of patient care, they are not the primary interventions for managing a suspected stroke.

5. A nurse is working in an acute care mental health facility and is assessing a client who has schizophrenia. Which of the following findings should the nurse expect?

• A. All-or-nothing thinking.
• B. Euphoric mood.
• C. Disorganized speech.
• D. Hypochondriasis.

Correct answer: C

Rationale: The correct answer is C: Disorganized speech. Disorganized speech is a hallmark symptom of schizophrenia, characterized by impaired thought processes that lead to incoherent, disjointed communication. All-or-nothing thinking (Choice A) is more commonly associated with cognitive distortions seen in conditions like anxiety disorders. Euphoric mood (Choice B) is not a typical finding in schizophrenia, as individuals with this disorder often display a flat or blunted affect. Hypochondriasis (Choice D) involves a preoccupation with having a serious illness and is not a primary symptom of schizophrenia.

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