Nursing Elites

1. A nurse is reviewing the medical history of a client with dementia. Which of the following findings should the nurse address first?

• A. Restlessness and agitation
• B. Decreased respiratory rate
• C. Wandering during the night
• D. Incontinence

Correct answer: A

Rationale: In a client with dementia, addressing restlessness and agitation is a priority because these symptoms can exacerbate dementia and lead to further complications. Restlessness and agitation can indicate underlying issues such as pain, discomfort, or unmet needs, which should be promptly assessed and managed to improve the client's quality of life. Decreased respiratory rate, wandering during the night, and incontinence are important to address but do not pose immediate risks to the client's well-being compared to the potential effects of unmanaged restlessness and agitation in dementia.

2. A nurse is caring for a client who is experiencing chronic pain. Which of the following interventions should the nurse implement?

• A. Provide the client with distractions such as television
• B. Administer pain medication around the clock
• C. Teach the client relaxation techniques
• D. Perform massage therapy on the client

Correct answer: C

Rationale: The correct intervention for a client experiencing chronic pain is to teach relaxation techniques, as it helps in managing pain more effectively by reducing stress and anxiety. Distractions like television (Choice A) may offer temporary relief but do not address the root cause of chronic pain. Administering pain medication around the clock (Choice B) may lead to dependency and not promote long-term pain management. While massage therapy (Choice D) can be beneficial, teaching relaxation techniques (Choice C) is more directly focused on empowering the client to manage their pain independently.

3. A nurse is caring for a client who is postoperative following hip replacement surgery. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

• A. Cross the client's legs at the knees
• B. Maintain the client's legs in a neutral position
• C. Avoid placing a pillow under the client's knees
• D. Elevate the client's legs

Correct answer: C

Rationale: The correct action to prevent dislocation of the prosthesis after hip replacement surgery is to avoid placing a pillow under the client's knees. Placing a pillow can cause hip adduction, leading to dislocation. Crossing the client's legs at the knees and elevating the client's legs can also increase the risk of hip dislocation. Maintaining the client's legs in a neutral position is important to prevent complications.

4. How should a healthcare professional manage a patient with fluid volume deficit?

• A. Encourage oral fluid intake
• B. Administer IV fluids as ordered
• C. Monitor urine output and check electrolyte levels
• D. Monitor skin turgor and capillary refill

Correct answer: A

Rationale: Encouraging oral fluid intake is a crucial nursing intervention in managing a patient with fluid volume deficit. By encouraging oral fluid intake, the patient can increase hydration levels, helping to correct the deficit. Administering IV fluids may be necessary in severe cases or when the patient is unable to tolerate oral intake. Monitoring urine output and checking electrolyte levels are essential aspects of assessing fluid volume status, but they are not direct interventions for correcting fluid volume deficit. Monitoring skin turgor and capillary refill are important assessments for fluid volume status but are not direct management strategies.

5. What is the priority nursing action for a patient with an acute asthma attack?

• A. Administer a bronchodilator
• B. Monitor oxygen saturation
• C. Position the patient in a high Fowler's position
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to administer a bronchodilator. During an acute asthma attack, the priority is to open the airways and improve breathing. Bronchodilators are the first-line treatment for asthma attacks as they help dilate the bronchioles, allowing for better airflow. Monitoring oxygen saturation is important but not the priority when the patient is in distress. Placing the patient in a high Fowler's position can help with breathing but is not the initial priority. Calling for assistance can be done after initiating the appropriate treatment.

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