Nursing Elites

1. A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following actions should the nurse take?

• A. Administer 0.9% sodium chloride IV
• B. Administer a hypotonic IV solution
• C. Encourage oral fluid intake
• D. Restrict oral fluid intake

Correct answer: A

Rationale: In a client with a sodium level of 125 mEq/L (hyponatremia), the nurse should administer 0.9% sodium chloride IV to help increase sodium levels. Choice B, administering a hypotonic IV solution, would further decrease the sodium level. Choice C, encouraging oral fluid intake, is contraindicated as it can dilute the sodium concentration further. Choice D, restricting oral fluid intake, could worsen the client's condition by leading to dehydration and further electrolyte imbalances.

2. A nurse is assessing a client who has hypovolemia. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Tachycardia.
• C. Increased blood pressure.
• D. Bounding pulse.

Correct answer: B

Rationale: The correct answer is B: Tachycardia. In hypovolemia, the body responds to decreased fluid volume by increasing the heart rate (tachycardia) to maintain adequate circulation. Bradycardia (Choice A) is not expected in hypovolemia since the heart rate typically increases to compensate for the reduced blood volume. Increased blood pressure (Choice C) is unlikely in hypovolemia as the decreased fluid volume leads to decreased pressure. A bounding pulse (Choice D) is more associated with conditions like hyperthyroidism or fever, not specifically with hypovolemia.

3. A nurse is planning care for a client who is postoperative following abdominal surgery. Which of the following interventions should the nurse implement to prevent respiratory complications?

• A. Encourage the client to ambulate twice daily.
• B. Encourage the client to deep breathe and cough every hour.
• C. Encourage the client to use an incentive spirometer every hour.
• D. Instruct the client to avoid coughing to prevent pain.

Correct answer: C

Rationale: The correct answer is C. Encouraging the client to use an incentive spirometer every hour is crucial to prevent respiratory complications postoperatively. Incentive spirometry helps in lung expansion and prevents atelectasis, which is common after abdominal surgery. Choice A, encouraging ambulation, is important for preventing complications but does not directly address respiratory issues. Choice B, deep breathing and coughing every hour, is also beneficial but not as effective in preventing atelectasis as using an incentive spirometer. Choice D, instructing the client to avoid coughing, is incorrect as coughing helps clear secretions and prevent respiratory complications.

4. How should a healthcare professional administer a subcutaneous injection?

• A. Insert the needle at a 45-degree angle
• B. Insert the needle at a 90-degree angle
• C. Use a Z-track method
• D. Insert the needle at a 15-degree angle

Correct answer: A

Rationale: The correct technique for administering subcutaneous injections is to insert the needle at a 45-degree angle. This angle ensures that the medication is delivered into the subcutaneous tissue, which is located just below the skin. Inserting the needle at a 90-degree angle is more appropriate for intramuscular injections, while using a Z-track method is specific to intramuscular injections to prevent leakage of medication into the subcutaneous tissue. Inserting the needle at a 15-degree angle would not reach the subcutaneous tissue effectively.

5. A nurse is planning care for a client who is experiencing acute mania. What intervention should the nurse include?

• A. Encourage the client to take frequent rest periods.
• B. Withdraw TV privileges if the client does not attend group therapy.
• C. Place the client in seclusion during periods of anxiety.
• D. Encourage the client to spend time in the day room.

Correct answer: A

Rationale: The correct answer is A: Encourage the client to take frequent rest periods. During acute mania, individuals often experience high levels of energy, decreased need for sleep, and increased activity levels. Encouraging the client to take frequent rest periods can help prevent exhaustion and promote better self-regulation. Choice B is incorrect because withdrawing TV privileges may not be directly related to managing acute mania. Choice C is incorrect as placing the client in seclusion can exacerbate feelings of anxiety and agitation. Choice D is incorrect as spending time in the day room may not address the need for rest and relaxation that is crucial during acute mania.

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