Nursing Elites

1. How should a healthcare professional assess a patient with suspected sepsis?

• A. Monitor vital signs and administer antibiotics
• B. Monitor for signs of infection and confusion
• C. Monitor for fever and check oxygen saturation
• D. Assess for confusion and administer fluids

Correct answer: A

Rationale: When assessing a patient with suspected sepsis, it is crucial to monitor vital signs like temperature, heart rate, respiratory rate, and blood pressure. Administering antibiotics promptly is also vital to treat the infection causing sepsis. This approach helps in preventing the progression of sepsis to severe stages and reduces the risk of complications. Choice B is incorrect because only monitoring signs of infection and confusion may delay necessary treatment with antibiotics. Choice C is incorrect as it focuses only on fever and oxygen saturation, missing other important vital signs. Choice D is incorrect because assessing for confusion alone is not sufficient, and administering fluids should be guided by the patient's fluid status rather than being an initial step in suspected sepsis assessment.

2. A nurse is reinforcing discharge teaching with a client who is postoperative following an open radical prostatectomy. Which of the following instructions should the nurse include in the teaching?

• A. Perform Kegel exercises daily
• B. Perform light exercise for 3 hours each day
• C. Avoid bathing for 3 days
• D. Avoid sitting in a chair for more than 2 hours

Correct answer: A

Rationale: The correct answer is A: Perform Kegel exercises daily. After a radical prostatectomy, Kegel exercises are beneficial as they help strengthen the pelvic floor muscles, aiding in urinary control and recovery. Choice B is incorrect because recommending 3 hours of light exercise daily may not be suitable immediately postoperatively. Choice C is incorrect as personal hygiene, including bathing, is important for postoperative care. Choice D is incorrect because sitting for more than 2 hours does not specifically relate to the client's postoperative care needs.

3. What are the key signs of respiratory distress?

• A. Increased respiratory rate and use of accessory muscles
• B. Decreased respiratory rate and cyanosis
• C. Cyanosis and use of accessory muscles
• D. Altered mental status and bradycardia

Correct answer: A

Rationale: The correct answer is A: Increased respiratory rate and use of accessory muscles are key signs of respiratory distress. When a person is experiencing respiratory distress, their respiratory rate typically increases as the body tries to compensate for the inadequate oxygenation. Additionally, the use of accessory muscles indicates that the person is working harder to breathe. Choices B, C, and D are incorrect because they do not accurately represent the key signs of respiratory distress. A decreased respiratory rate, cyanosis, altered mental status, and bradycardia are not typical signs of respiratory distress.

4. A nurse is providing care for a client with dementia who frequently wanders. What is the best strategy to ensure their safety?

• A. Use restraints to prevent wandering
• B. Encourage the client to walk in a monitored area
• C. Place a bed exit alarm system
• D. Ask family members to stay with the client at all times

Correct answer: C

Rationale: The best strategy to ensure the safety of a client with dementia who frequently wanders is to place a bed exit alarm system. This system alerts staff when the client attempts to leave the bed, reducing the risk of falls. Choice A, using restraints, is not the best approach as it can lead to complications and is not recommended unless absolutely necessary. Choice B, encouraging the client to walk in a monitored area, may not be effective in preventing wandering as the client may still wander away. Choice D, asking family members to stay with the client at all times, may not be feasible or practical, especially for round-the-clock supervision.

5. How should a healthcare professional respond to a patient with hypokalemia?

• A. Administer potassium supplements and monitor ECG
• B. Restrict fluid intake and provide a high-sodium diet
• C. Monitor sodium levels and provide insulin therapy
• D. Provide calcium supplements and monitor for hyperkalemia

Correct answer: A

Rationale: Hypokalemia is managed by administering potassium supplements to correct the low potassium levels in the body. Monitoring the ECG is essential because low potassium levels can lead to cardiac arrhythmias. Choice B is incorrect as restricting fluid intake and providing a high-sodium diet are not appropriate for managing hypokalemia. Choice C is incorrect because hypokalemia involves low potassium levels, not sodium levels, and insulin therapy does not directly address this issue. Choice D is incorrect as calcium supplements are not indicated for hypokalemia, and monitoring for hyperkalemia is not relevant in this case.

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