Nursing Elites

1. What are the signs and symptoms of a pulmonary embolism?

• A. Sudden shortness of breath
• B. Chest pain
• C. Cough with blood
• D. All of the above

Correct answer: D

Rationale: A pulmonary embolism can manifest with sudden shortness of breath, chest pain, and coughing up blood. These symptoms are classic presentations of a pulmonary embolism due to the blockage of blood flow to the lungs. Therefore, the correct answer is 'All of the above.' Each symptom alone can be seen in various other conditions, but when occurring together, they strongly suggest a pulmonary embolism. Sudden shortness of breath is due to decreased oxygenation, chest pain can result from the strain on the heart, and coughing with blood may indicate damage to the lung tissue. Choosing any single symptom would not encompass the full range of presentations seen in a pulmonary embolism.

2. How can a healthcare professional reduce the risk of falls in elderly patients?

• A. Encourage the use of assistive devices.
• B. Clear walkways.
• C. Ensure proper lighting.
• D. All of the above.

Correct answer: D

Rationale: All of these interventions are crucial in reducing the risk of falls in elderly patients. Encouraging the use of assistive devices helps provide support and stability, clearing walkways minimizes tripping hazards, and ensuring proper lighting enhances visibility and reduces the chances of falls. Therefore, choosing 'All of the above' is the most appropriate answer as each intervention plays a significant role in fall prevention.

3. A nurse is collecting data from a client who delivered a full-term newborn 16 hours ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer pain medication
• B. Perform a fundal massage for the client
• C. Check the baby's heart rate
• D. Apply an ice pack

Correct answer: B

Rationale: The correct action the nurse should take first when noting excessive lochia discharge in a client who delivered a full-term newborn 16 hours ago is to perform a fundal massage. Fundal massage helps stimulate uterine contractions, which in turn reduces bleeding in postpartum clients. Administering pain medication (Choice A) is not the priority in this situation as addressing the excessive lochia discharge is crucial to prevent complications. Checking the baby's heart rate (Choice C) is important but not the first action to manage the mother's condition. Applying an ice pack (Choice D) is not appropriate for managing excessive lochia discharge; fundal massage is the initial intervention to address this issue effectively.

4. A client has an NG tube that needs to be irrigated every 8 hours. Which solution should the nurse use to maintain fluid and electrolyte balance?

• A. Tap water
• B. Sterile water
• C. 0.9% sodium chloride
• D. 0.45% sodium chloride

Correct answer: C

Rationale: The correct solution to maintain fluid and electrolyte balance during NG tube irrigation is 0.9% sodium chloride. This solution is isotonic and helps prevent electrolyte imbalances. Using tap water or sterile water can lead to electrolyte disturbances due to their hypotonic nature, while 0.45% sodium chloride is hypotonic and may cause further imbalances in the client's electrolyte levels.

5. What are the key nursing interventions for a patient receiving diuretic therapy?

• A. Monitor electrolyte levels and administer potassium as needed
• B. Restrict fluid intake and provide a low-sodium diet
• C. Encourage oral fluids and increase dietary potassium
• D. Provide high-sodium foods to improve electrolyte balance

Correct answer: A

Rationale: The correct answer is A: Monitor electrolyte levels and administer potassium as needed. Patients on diuretic therapy are at risk of electrolyte imbalances, particularly low potassium levels. Monitoring electrolytes and administering potassium as needed are crucial nursing interventions to prevent imbalances. Choice B is incorrect because restricting fluid intake and providing a low-sodium diet are not typically indicated for patients on diuretic therapy. Choice C is incorrect as encouraging oral fluids and increasing dietary potassium can exacerbate electrolyte imbalances in patients on diuretics. Choice D is incorrect as providing high-sodium foods would worsen electrolyte balance issues in patients on diuretic therapy.

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