Nursing Elites

1. How should a healthcare professional assess a patient with hyperkalemia?

• A. Monitor ECG and administer insulin
• B. Monitor blood glucose levels and provide fluids
• C. Monitor for muscle weakness and administer calcium gluconate
• D. Monitor electrolyte levels and provide potassium supplements

Correct answer: A

Rationale: Corrected Question: When assessing a patient with hyperkalemia, monitoring the ECG and administering insulin are crucial steps. Hyperkalemia can affect the heart's function, leading to life-threatening arrhythmias. Monitoring the ECG helps in identifying any cardiac abnormalities associated with high potassium levels. Administering insulin, along with glucose, helps shift potassium from the bloodstream into the cells, temporarily lowering the potassium levels. Choice B is incorrect because monitoring blood glucose levels and providing fluids are not the primary interventions for hyperkalemia. Choice C is incorrect as monitoring for muscle weakness and administering calcium gluconate are not the first-line treatments for hyperkalemia. Calcium gluconate may be used in specific situations to stabilize cardiac cell membranes in severe cases of hyperkalemia. Choice D is incorrect because monitoring electrolyte levels and providing potassium supplements would worsen hyperkalemia, as the patient already has elevated potassium levels and does not require additional potassium supplementation.

2. A nurse is teaching a client who has ulcerative colitis about dietary recommendations. Which of the following instructions should the nurse include?

• A. Avoid high-fiber foods
• B. Increase intake of spicy foods
• C. Consume foods high in fiber
• D. Eat large, infrequent meals

Correct answer: C

Rationale: The correct answer is C: 'Consume foods high in fiber.' Consuming high-fiber foods helps manage symptoms of ulcerative colitis by promoting regular bowel movements. Choices A, B, and D are incorrect. Avoiding high-fiber foods can worsen symptoms as fiber is beneficial for digestive health. Increasing the intake of spicy foods can exacerbate inflammation in the digestive tract, leading to more discomfort. Eating large, infrequent meals can put more strain on the digestive system, which is not ideal for managing ulcerative colitis.

3. A client with diabetes mellitus is experiencing hypoglycemia. Which of the following actions should the nurse take?

• A. Administer insulin
• B. Administer glucagon
• C. Administer 4 oz of orange juice
• D. Administer 1 L of water

Correct answer: C

Rationale: Administering 4 oz of orange juice is the appropriate action for a client experiencing hypoglycemia due to diabetes mellitus. Orange juice contains simple sugars that can quickly raise blood glucose levels. Insulin (Choice A) would further lower blood sugar, worsening the condition. Glucagon (Choice B) is used in severe hypoglycemia when the client cannot take anything by mouth. Administering 1 L of water (Choice D) is not indicated in hypoglycemia treatment; the priority is to raise blood sugar levels. Therefore, the correct choice is to administer orange juice to address the low blood sugar in this situation.

4. What is the most important intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Monitor airway patency
• C. Provide bronchodilators
• D. Call for assistance

Correct answer: A

Rationale: Administering oxygen is crucial in managing a patient experiencing respiratory distress. Oxygen therapy helps to improve oxygen levels in the blood, supporting vital organ functions. While monitoring airway patency is important, administering oxygen takes precedence in ensuring the patient receives an adequate oxygen supply. Providing bronchodilators may be beneficial in certain respiratory conditions, but the immediate priority in distress is to address oxygenation. Calling for assistance is essential, but the immediate intervention to support the patient's respiratory function is administering oxygen.

5. A nurse is teaching a client who is to undergo radiation therapy for breast cancer about potential adverse effects. Which of the following adverse effects should the nurse include in the teaching?

• A. Fatigue
• B. Constipation
• C. Hair loss
• D. Weight gain

Correct answer: A

Rationale: The correct adverse effect that the nurse should include in the teaching is fatigue. Fatigue is a common side effect of radiation therapy, particularly with prolonged treatment. Constipation, hair loss, and weight gain are not typically associated with radiation therapy for breast cancer, making them incorrect choices. Fatigue can significantly impact a patient's quality of life during treatment and should be addressed proactively by healthcare providers.

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