Nursing Elites

1. A client is being cared for by a nurse with dehydration. What is the priority intervention?

• A. Administer antiemetics to reduce nausea
• B. Encourage the client to drink oral rehydration solutions
• C. Monitor the client's fluid and electrolyte levels
• D. Administer intravenous fluids

Correct answer: C

Rationale: The correct answer is to monitor the client's fluid and electrolyte levels. When caring for a client with dehydration, it is crucial to assess and monitor their fluid and electrolyte status to guide appropriate interventions. Administering antiemetics may help with nausea but does not address the underlying issue of dehydration. Encouraging the client to drink oral rehydration solutions is beneficial but may not be the immediate priority if the client is severely dehydrated. Administering intravenous fluids may be necessary based on the assessment of fluid and electrolyte levels, making monitoring these levels the priority intervention.

2. What are the key signs of increased intracranial pressure (ICP) that a nurse should monitor for?

• A. Monitor for changes in level of consciousness
• B. Check for pupil dilation
• C. Assess for bradycardia
• D. Monitor for vomiting

Correct answer: A

Rationale: The correct answer is A: 'Monitor for changes in the level of consciousness.' Key signs of increased intracranial pressure (ICP) include changes in the level of consciousness and pupil dilation. Assessing for bradycardia and monitoring for vomiting are not typically considered primary signs of increased ICP. While bradycardia and vomiting can occur with increased ICP, they are not as specific or sensitive as changes in consciousness and pupil dilation.

3. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

• A. Eat a light snack before bedtime.
• B. Stay in bed at least 1 hr if unable to fall asleep.
• C. Take a 1 hr nap during the day.
• D. Perform exercises prior to bedtime.

Correct answer: A

Rationale: The correct answer is to instruct the older adult client to eat a light snack before bedtime. This is beneficial as it helps prevent hunger, which can disrupt sleep. Choice B is incorrect as staying in bed for a prolonged time if unable to fall asleep can lead to frustration and worsen insomnia. Choice C is incorrect as taking a 1-hour nap during the day can interfere with the ability to fall asleep at night. Choice D is incorrect as performing exercises prior to bedtime can increase alertness and make it harder to fall asleep.

4. A nurse is providing discharge instructions for a client using home oxygen. What is the most important safety measure?

• A. Store oxygen tanks in a closet when not in use
• B. Ensure that oxygen tanks are kept upright and away from heat sources
• C. Allow family members to smoke in designated areas
• D. Restrict fluid intake while using oxygen

Correct answer: B

Rationale: The correct answer is B: Ensure that oxygen tanks are kept upright and away from heat sources. This is the most important safety measure to prevent accidents related to home oxygen use. Storing oxygen tanks in a closet when not in use (choice A) is not recommended as they should be stored in a well-ventilated area. Allowing family members to smoke in designated areas (choice C) poses a significant fire hazard. Restricting fluid intake while using oxygen (choice D) is not a safety measure related to oxygen use.

5. What are the nursing considerations when administering blood products?

• A. Monitor vital signs and check for allergic reactions
• B. Verify blood type and compatibility before transfusion
• C. Monitor for signs of infection and sepsis
• D. Ensure consent is signed and prepare for possible reaction

Correct answer: A

Rationale: The correct answer is A: Monitor vital signs and check for allergic reactions. When administering blood products, monitoring vital signs such as blood pressure, heart rate, and temperature is crucial to detect any adverse reactions promptly. Checking for allergic reactions, such as hives, itching, or difficulty breathing, is essential to ensure patient safety. Choice B is incorrect because verifying blood type and compatibility is typically done by the laboratory before the blood is issued for transfusion. Choice C is not a direct nursing consideration during the administration of blood products. While monitoring for signs of infection and sepsis is important in general patient care, it is not specific to blood transfusions. Choice D is also incorrect as ensuring consent is signed and preparing for possible reactions are important but do not directly relate to the immediate nursing considerations during blood product administration.

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