Nursing Elites

1. 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.

2. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates a hemolytic transfusion reaction?

• A. Chills
• B. Bradycardia
• C. Hypertension
• D. Low back pain

Correct answer: D

Rationale: Low back pain is a classic sign of a hemolytic transfusion reaction and requires immediate intervention. Chills are more commonly associated with a febrile non-hemolytic transfusion reaction. Bradycardia is not a typical sign of a hemolytic transfusion reaction. Hypertension is not a common finding in a hemolytic transfusion reaction.

3. What is the priority in managing a client diagnosed with delirium?

• A. Administer anti-anxiety medication
• B. Identify any underlying causes of delirium
• C. Reduce environmental stimulation to calm the client
• D. Encourage deep breathing exercises

Correct answer: B

Rationale: The priority in managing a client diagnosed with delirium is to identify any underlying causes. Delirium can be caused by various factors such as infections, medications, or metabolic imbalances. By determining the root cause, healthcare providers can address the issue effectively and tailor the treatment plan accordingly. Administering anti-anxiety medication (Choice A) may help manage symptoms but does not address the underlying cause of delirium. Similarly, reducing environmental stimulation (Choice C) and encouraging deep breathing exercises (Choice D) may provide some relief, but they do not target the primary concern of identifying and addressing the underlying causes of delirium.

4. A nurse is collecting data from a newly-admitted infant who is 3 months old and has diarrhea. Which of the following findings should the nurse report to the provider?

• A. Weight gain
• B. Poor appetite
• C. Irritability
• D. Decreased urination

Correct answer: C

Rationale: Irritability in infants can indicate worsening dehydration, which needs to be reported. Weight gain (Choice A) would be a positive finding, indicating adequate fluid intake. Poor appetite (Choice B) is common with diarrhea but not as concerning as irritability. Decreased urination (Choice D) can also be a sign of dehydration, but irritability is more specific to worsening dehydration in this case.

5. What is the first intervention for a patient in shock?

• A. Administer fluids
• B. Monitor blood pressure
• C. Provide oxygen
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to administer fluids. In a patient experiencing shock, the priority is to address inadequate perfusion by restoring circulating blood volume. Administering fluids helps improve perfusion and oxygen delivery to vital organs. Monitoring blood pressure, providing oxygen, and calling for assistance are important steps but administering fluids is the initial and most critical intervention in the management of shock.

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