Nursing Elites

1. 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.

2. What are the signs of hypoglycemia, and how should a healthcare provider respond to a patient experiencing this condition?

• A. Shakiness or Tremors
• B. Confusion or Irritability
• C. Hunger
• D. Dizziness or Lightheadedness

Correct answer: A

Rationale: The signs of hypoglycemia include shakiness, confusion, hunger, dizziness, and lightheadedness. However, the classic and most common early sign is shakiness or tremors. When a patient is experiencing hypoglycemia, a healthcare provider should respond promptly by administering glucose to raise the blood sugar levels. Choice A is correct as it directly addresses one of the primary signs of hypoglycemia. Choices B, C, and D are incorrect because while confusion, irritability, hunger, dizziness, and lightheadedness can also be signs of hypoglycemia, shakiness or tremors are the classic and most common early symptoms that healthcare providers should be particularly vigilant for.

3. A client with a new prescription for prednisone for the treatment of Addison's disease needs teaching. Which instruction should the nurse include?

• A. Take the medication with food
• B. Avoid taking aspirin
• C. Schedule a bone density test
• D. Expect increased appetite

Correct answer: C

Rationale: The correct instruction for the nurse to include is to schedule a bone density test. Prednisone can lead to reduced bone density, making regular monitoring crucial for clients on long-term therapy. Instructing the client to take the medication with food (choice A) or avoid taking aspirin (choice B) are not directly related to prednisone therapy for Addison's disease. While prednisone can cause increased appetite, it is not the priority instruction in this scenario, compared to monitoring bone density (choice D).

4. A nurse has administered medications to a group of clients. For which of the following client situations should the nurse complete an incident report?

• A. Administering acetaminophen to an NPO client
• B. Administering insulin lispro to an NPO client
• C. Administering medication to the incorrect client
• D. Administering anticoagulants without checking INR

Correct answer: B

Rationale: The correct answer is B because administering insulin lispro to an NPO client can lead to hypoglycemia due to the lack of food to balance the medication. This situation poses a serious risk to the client's safety and should be documented in an incident report. Choice A is not as critical as insulin administration for an NPO client. Choice C is also serious but does not pose an immediate risk to the client's health. Choice D, administering anticoagulants without checking the INR, is important but does not require an incident report unless adverse effects occur, as it may not immediately endanger the client's life.

5. What is the primary intervention for a patient with a pneumothorax?

• A. Insert a chest tube
• B. Administer oxygen
• C. Monitor respiratory rate
• D. Administer analgesics

Correct answer: A

Rationale: The correct answer is to insert a chest tube. This intervention is considered the definitive treatment for a pneumothorax as it helps remove air or fluid from the pleural space, re-expanding the lung. Administering oxygen (Choice B) can be supportive but is not the primary intervention to treat a pneumothorax. Monitoring respiratory rate (Choice C) is important but does not address the underlying issue of air in the pleural space. Administering analgesics (Choice D) may help manage pain but does not treat the pneumothorax itself.

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