Nursing Elites

1. A client has hyperthermia. Which of the following actions should the nurse take?

• A. Submerge the client's feet in ice water.
• B. Cover the client with a thermal blanket.
• C. Administer oral acetaminophen.
• D. Initiate seizure precautions.

Correct answer: C

Rationale: Administering oral acetaminophen is the appropriate intervention for a client with hyperthermia. Acetaminophen helps to reduce fever by lowering the body's temperature. Submerging the client's feet in ice water can lead to shock and is not recommended. Using a thermal blanket may worsen the condition by trapping heat. Initiating seizure precautions is not directly related to managing hyperthermia.

2. 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.

3. How should a healthcare professional assess a patient with fluid overload?

• A. Monitor weight and assess for edema
• B. Monitor blood pressure and auscultate lung sounds
• C. Assess for jugular venous distention
• D. Monitor oxygen saturation and check for fluid retention

Correct answer: A

Rationale: The correct way to assess a patient with fluid overload is by monitoring weight and assessing for edema. Weight monitoring helps in detecting fluid retention, and edema is a visible sign of excess fluid accumulation. Although monitoring blood pressure and auscultating lung sounds are important assessments in heart failure, they are not specific to fluid overload. Assessing for jugular venous distention is more indicative of right-sided heart failure rather than fluid overload. Monitoring oxygen saturation and checking for fluid retention are not primary assessments for fluid overload.

4. A nurse is contributing to an in-service for newly-licensed nurses about child maltreatment. The nurse should include that which of the following characteristics increases a child's risk of physical maltreatment?

• A. Low birth weight
• B. Advanced maternal age
• C. Single parenthood
• D. Premature birth

Correct answer: A

Rationale: Low birth weight increases a child's vulnerability to physical maltreatment due to additional care needs. Advanced maternal age (choice B) is not directly linked to an increased risk of physical maltreatment. Single parenthood (choice C) is not a characteristic that inherently increases the risk of physical maltreatment. Premature birth (choice D) is not listed as a characteristic that directly increases a child's risk of physical maltreatment.

5. A nurse is caring for a client who is being discharged home following a cerebrovascular accident. Which of the following documents should the nurse plan to include with the discharge report?

• A. List of prescribed medications
• B. Potential complications to report
• C. Family contact details
• D. Dietary restrictions

Correct answer: B

Rationale: The correct answer is B: Potential complications to report. Including potential complications in the discharge report is crucial for ensuring proper follow-up care. This information helps the client and their caregivers to be aware of warning signs that may indicate a worsening condition or the need for immediate medical attention. Choices A, C, and D are important aspects of discharge planning, but providing a list of potential complications to report takes precedence as it directly impacts the client's safety and well-being post-discharge.

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