Nursing Elites

1. What is the best nursing intervention for a patient experiencing fluid overload?

• A. Administer diuretics
• B. Administer IV fluids
• C. Provide oral fluids
• D. Provide chest physiotherapy

Correct answer: A

Rationale: The best nursing intervention for a patient experiencing fluid overload is to administer diuretics. Diuretics help the body to remove excess fluid by increasing urine output. This intervention is crucial in managing fluid overload. Administering IV fluids (Choice B) would worsen the condition by adding more fluids to the already overloaded system. Providing oral fluids (Choice C) is not appropriate as it would further contribute to the fluid overload. Chest physiotherapy (Choice D) is not indicated in the treatment of fluid overload and would not address the underlying issue of excess fluid accumulation.

2. What is the first intervention for a patient experiencing anaphylactic shock?

• A. Administer epinephrine
• B. Administer corticosteroids
• C. Administer antihistamines
• D. Administer oxygen

Correct answer: A

Rationale: The correct answer is to administer epinephrine as the first intervention for a patient experiencing anaphylactic shock. Epinephrine is crucial in reversing the allergic reaction and restoring cardiovascular stability. Corticosteroids (Choice B) are not the first-line treatment for anaphylactic shock but may be used as an adjunct therapy. Antihistamines (Choice C) can help relieve itching and hives but are not as effective as epinephrine in treating the systemic effects of anaphylaxis. Oxygen (Choice D) may be necessary to support breathing in severe cases of anaphylaxis, but administering epinephrine takes precedence in the management of anaphylactic shock.

3. A client is being taught about patient-controlled analgesia (PCA). Which statement should be included in the teaching?

• A. The PCA will deliver a double dose of medication when you push the button twice.
• B. Continuous PCA infusion is designed to allow fluctuating plasma medication levels.
• C. You should push the button before physical activity to allow maximum pain control.
• D. You can adjust the amount of pain medication you receive by pushing on the keypad.

Correct answer: D

Rationale: The correct statement to include in the teaching about PCA is that the client can adjust the amount of pain medication they receive by pushing on the keypad. This empowers the client to control their pain management effectively. Choice A is incorrect because PCA systems are programmed to prevent double dosing when the button is pressed multiple times in quick succession. Choice B is incorrect as continuous PCA infusion aims to maintain a steady plasma medication level. Choice C is incorrect because it is not necessary to push the button before physical activity to ensure maximum pain control; the client should use the PCA as needed for pain relief.

4. A client with a new colostomy requires care planning by a nurse. Which of the following interventions should the nurse include in the plan of care?

• A. Change the ostomy pouch every 4 to 7 days.
• B. Empty the ostomy pouch when it is half full.
• C. Apply a skin barrier around the stoma.
• D. Cleanse the peristomal skin with alcohol.

Correct answer: A

Rationale: The correct answer is to change the ostomy pouch every 4 to 7 days. This practice helps prevent skin irritation and leakage by maintaining a clean and secure seal around the stoma. Option B is incorrect because it is more important to change the pouch regularly rather than emptying it when half full. Option C is incorrect as applying a skin barrier is typically done during the initial application of the pouch, not during regular changes. Option D is incorrect because alcohol can be too harsh for the peristomal skin and can cause irritation.

5. A nurse is caring for a client who has Crohn's disease. Which of the following findings should the nurse expect?

• A. Weight gain.
• B. Bloody stools.
• C. Urinary retention.
• D. Abdominal distention.

Correct answer: B

Rationale: The correct answer is B: Bloody stools. Bloody stools are a common symptom of Crohn's disease, characterized by inflammation of the digestive tract. Weight gain (choice A) is less likely due to malabsorption issues associated with Crohn's disease. Urinary retention (choice C) is not directly related to Crohn's disease. Abdominal distention (choice D) may occur in Crohn's disease but is not as specific a finding as bloody stools.

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