Nursing Elites

1. A nurse is collecting data from a school-age child who has sustained a skull fracture. Which of the following is a manifestation of increased intracranial pressure?

• A. Nausea
• B. Confusion about own name
• C. Rapid pulse
• D. Vomiting

Correct answer: B

Rationale: Confusion, especially about one's own name, is a sign of increased intracranial pressure and should be addressed. Nausea and vomiting are common symptoms of increased intracranial pressure, but confusion about personal information is a more specific and critical indication that requires immediate attention. Rapid pulse may be a possible response to increased intracranial pressure, but it is not as specific as confusion about own name in this scenario.

2. A client with a tracheostomy is exhibiting signs of respiratory distress. What is the first action the nurse should take?

• A. Increase the suction setting on the ventilator
• B. Suction the tracheostomy
• C. Notify the physician immediately
• D. Encourage deep breathing exercises

Correct answer: B

Rationale: The correct first action for a client with a tracheostomy exhibiting signs of respiratory distress is to suction the tracheostomy. This helps clear the airway and improve breathing. Increasing the suction setting on the ventilator is not appropriate as the issue may be related to secretions that need to be directly removed. Notifying the physician should come after providing immediate nursing interventions. Encouraging deep breathing exercises is not suitable when the client is in respiratory distress and needs prompt intervention.

3. How should a healthcare professional monitor a patient receiving IV potassium?

• A. Monitor ECG for dysrhythmias
• B. Monitor urine output
• C. Monitor serum potassium levels
• D. All of the above

Correct answer: D

Rationale: When a patient is receiving IV potassium, it is crucial to monitor various parameters to ensure patient safety. Monitoring the ECG helps in identifying any potential dysrhythmias that may occur due to potassium imbalances. Monitoring urine output is important as potassium levels can affect renal function. Monitoring serum potassium levels is essential to assess the effectiveness of the IV potassium therapy. Therefore, all the options - monitoring ECG for dysrhythmias, urine output, and serum potassium levels - are necessary when administering IV potassium, making 'All of the above' the correct answer. Choices A, B, and C are not individually sufficient as they each address different aspects of patient monitoring when receiving IV potassium.

4. A nurse is providing discharge instructions to a client with home oxygen therapy. Which of the following is essential for safety?

• A. Allow the client to smoke in designated outdoor areas
• B. Place the oxygen equipment 10 feet away from any open flames
• C. Keep oxygen tanks upright at all times
• D. Restrict fluid intake while using oxygen

Correct answer: C

Rationale: The correct answer is to keep oxygen tanks upright at all times. This is essential for safety as it prevents the tanks from falling and causing injury. Allowing the client to smoke in designated outdoor areas (Choice A) is unsafe as smoking near oxygen equipment can lead to a fire. Placing the oxygen equipment 10 feet away from any open flames (Choice B) is important to prevent fire hazards, but keeping the tanks upright is more directly related to preventing injuries. Restricting fluid intake while using oxygen (Choice D) is not necessary for safety in home oxygen therapy.

5. A nurse is teaching a client who has gastroesophageal reflux disease (GERD) about ways to reduce symptoms. Which of the following instructions should the nurse include?

• A. Avoid lying down after meals
• B. Eat large meals to reduce acid production
• C. Drink carbonated beverages with meals
• D. Consume spicy foods to improve digestion

Correct answer: A

Rationale: The correct answer is A: 'Avoid lying down after meals.' This instruction is important for clients with GERD as it helps reduce reflux symptoms. Lying down after meals can worsen GERD symptoms by allowing stomach acid to flow back into the esophagus. Choice B is incorrect because eating large meals can actually increase acid production and exacerbate GERD symptoms. Choice C is incorrect as carbonated beverages can trigger acid reflux in individuals with GERD. Choice D is also incorrect because consuming spicy foods can irritate the esophagus and lead to increased reflux symptoms.

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