Nursing Elites

1. What are the nursing interventions for a patient with acute kidney injury (AKI)?

• A. Preparing the patient for dialysis if necessary
• B. Providing dietary modifications to reduce potassium
• C. Monitoring urine output and electrolytes
• D. Administering fluids and monitoring blood pressure

Correct answer: A

Rationale: The correct nursing intervention for a patient with acute kidney injury (AKI) includes preparing the patient for dialysis if necessary. While choices B, C, and D are also important aspects of managing AKI, the critical intervention in severe cases is to prepare the patient for dialysis to support kidney function. Providing dietary modifications to reduce potassium, monitoring urine output and electrolytes, and administering fluids are essential components of the overall care plan for AKI patients, but in cases where the condition is severe or if conservative management fails, dialysis may be required to support the patient's kidney function and prevent further complications.

2. A healthcare provider is planning care for a client who has fluid overload. Which of the following actions should the provider plan to take first?

• A. Assess for edema
• B. Evaluate electrolytes
• C. Restrict fluid intake
• D. Administer diuretics

Correct answer: B

Rationale: Evaluating electrolytes is crucial when addressing fluid overload as it helps determine the severity of the imbalance and guides treatment. Assessing for edema (Choice A) is important but not the priority over evaluating electrolytes. Restricting fluid intake (Choice C) and administering diuretics (Choice D) are interventions that may be necessary but should be based on the electrolyte evaluation to ensure safe and effective care.

3. A nurse in the PACU is caring for a client who has received general anesthesia and has a manifestation of malignant hyperthermia. The nurse should expect to administer which of the following medications?

• A. Acetaminophen
• B. Ibuprofen
• C. Dantrolene
• D. Diazepam

Correct answer: C

Rationale: Corrected Rationale: Dantrolene is the medication of choice to treat malignant hyperthermia, a life-threatening reaction to general anesthesia. It works by inhibiting the release of calcium ions in skeletal muscle cells, preventing muscle contracture and hypermetabolism. Acetaminophen (Choice A) and ibuprofen (Choice B) are not indicated for treating malignant hyperthermia. Diazepam (Choice D) may be used to control muscle spasms but is not the first-line treatment for malignant hyperthermia.

4. A patient with severe pain and leg swelling is admitted. What should the nurse assess for?

• A. Check for signs of deep vein thrombosis.
• B. Assess for compartment syndrome.
• C. Increase the patient's fluid intake.
• D. Prepare the patient for surgery to relieve pain.

Correct answer: B

Rationale: When a patient presents with severe pain and leg swelling, the nurse should assess for compartment syndrome. Compartment syndrome is a serious condition that can develop due to increased pressure within a muscle compartment, leading to compromised circulation and potential tissue damage. It is crucial to identify compartment syndrome promptly as it may require immediate intervention to prevent further complications. Checking for signs of deep vein thrombosis (Choice A) is also important in a patient with leg swelling, but in this scenario, the focus should be on assessing for compartment syndrome due to the severity of the symptoms. Increasing fluid intake (Choice C) may not address the underlying cause of the patient's symptoms. Preparing the patient for surgery (Choice D) without a comprehensive assessment and diagnosis is premature and may not be the appropriate initial intervention.

5. A client undergoing surgery refuses to remove religious jewelry. What is the best course of action?

• A. Proceed with surgery while securing the jewelry to the patient.
• B. Remove the jewelry and document the removal.
• C. Document the refusal and delay the surgery.
• D. Remove the jewelry with the family's permission.

Correct answer: B

Rationale: The correct course of action is to remove the jewelry and document the removal. While religious beliefs should be respected, ensuring patient safety during surgery is crucial. Securing the jewelry may not be sufficient to prevent any interference during the surgical procedure. Documenting the removal is important for legal and documentation purposes. Delaying the surgery or removing the jewelry with the family's permission may not be the best options as patient safety should be the top priority in this situation.

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