Nursing Elites

1. 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.

2. A nurse is teaching a client who is to undergo total knee arthroplasty about postoperative care. Which of the following instructions should the nurse include?

• A. Apply heat to the affected knee
• B. Avoid placing pillows under the knee
• C. Avoid moving the knee for 2-3 days
• D. Apply ice to the affected knee for 24-48 hours

Correct answer: D

Rationale: The correct answer is to apply ice to the affected knee for 24-48 hours. Applying ice helps to reduce inflammation and pain after knee surgery, promoting healing. Choice A is incorrect because heat is not recommended postoperatively, as it can increase swelling. Choice B is incorrect because pillows should be placed under the knee to keep it elevated. Choice C is incorrect because early mobilization is essential for preventing complications such as blood clots.

3. What is the priority nursing action for a dehydrated client who needs fluids?

• A. Administer antiemetics to prevent vomiting
• B. Monitor electrolyte levels frequently
• C. Administer oral rehydration solutions
• D. Insert an NG tube for fluid administration

Correct answer: B

Rationale: The correct answer is to monitor electrolyte levels frequently. When a client is dehydrated and needs fluids, it is essential to monitor electrolyte levels to prevent complications such as electrolyte imbalances. Administering antiemetics to prevent vomiting (Choice A) may be necessary but is not the priority when addressing dehydration. Administering oral rehydration solutions (Choice C) can be beneficial, but monitoring electrolyte levels takes precedence to ensure proper hydration. Inserting an NG tube for fluid administration (Choice D) is invasive and not typically the first-line approach for managing dehydration.

4. When managing a physically assaultive client, the nurse's INITIAL priority is to

• A. Restrict the client to the room
• B. Place the client under one-to-one supervision
• C. Restore the client's self-control and prevent further loss of control
• D. Clear the immediate area of other clients to prevent harm

Correct answer: C

Rationale: When dealing with a physically assaultive client, the initial priority is to focus on restoring the client's self-control and preventing further escalation. Restricting the client to the room (choice A) may escalate the situation and is not the initial priority. Placing the client under one-to-one supervision (choice B) is important but comes after ensuring the client's self-control. Clearing the immediate area of other clients (choice D) is essential for safety but is not the initial priority when compared to restoring the client's self-control.

5. What is the priority when managing a client with a chest tube postoperatively?

• A. Clamp the chest tube for 30 minutes every 4 hours
• B. Check for air leaks and proper functioning of the chest tube
• C. Encourage deep breathing and coughing every 2 hours
• D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The priority when managing a client with a chest tube postoperatively is to check for air leaks and ensure the proper functioning of the chest tube. This is crucial to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube intermittently can lead to a buildup of pressure in the pleural space and should not be done without a specific medical indication. Encouraging deep breathing and coughing helps with lung expansion but is not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing may increase the risk of dislodging the chest tube or causing complications.

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