Nursing Elites

1. What is the best nursing intervention for a patient with hyperkalemia?

• A. Administer potassium-wasting diuretics
• B. Encourage a low-potassium diet
• C. Administer potassium supplements
• D. Administer IV fluids

Correct answer: A

Rationale: The correct answer is to administer potassium-wasting diuretics. Hyperkalemia, which is high potassium levels, is managed by promoting the excretion of potassium from the body. Potassium-wasting diuretics help the kidneys eliminate excess potassium. Encouraging a low-potassium diet (choice B) is important for long-term management but not the immediate intervention for hyperkalemia. Administering potassium supplements (choice C) would worsen the condition by further increasing potassium levels. Administering IV fluids (choice D) may help with hydration but does not directly address the high potassium levels characteristic of hyperkalemia.

2. A client is learning to use a cane. What instruction is essential for this client?

• A. Advance the cane and the weaker leg at the same time
• B. Maintain two points of support on the ground at all times
• C. Use the cane on the weaker side for better support
• D. Advance the cane 30 to 45 cm with each step

Correct answer: B

Rationale: The correct instruction for a client learning to use a cane is to maintain two points of support on the ground at all times. This ensures better stability and reduces the risk of falls. Choice A is incorrect because advancing the cane and the weaker leg simultaneously may lead to imbalance. Choice C is incorrect because the cane should be used on the stronger side to provide support. Choice D is incorrect because there is no specific measurement for advancing the cane with each step, and the focus should be on maintaining stability.

3. A client with heart failure is receiving furosemide. Which of the following assessment findings indicates that the medication is effective?

• A. Elevated blood pressure.
• B. Absence of adventitious breath sounds.
• C. Weight gain of 1.4 kg (3 lb) in 24 hr.
• D. Decreased urine output.

Correct answer: B

Rationale: The absence of adventitious breath sounds indicates that furosemide is effective in managing heart failure. Adventitious breath sounds such as crackles indicate fluid accumulation in the lungs, a common complication of heart failure. Therefore, the absence of these abnormal sounds suggests that furosemide is effectively reducing fluid overload. Elevated blood pressure (choice A) is not a desired outcome in heart failure management. Weight gain (choice C) and decreased urine output (choice D) are signs of fluid retention and ineffective diuresis, indicating that furosemide is not working effectively.

4. A nurse is caring for a client following an acute myocardial infarction who is concerned about fatigue. What is the best strategy to promote independence in self-care?

• A. Instruct the client to remain in bed until the fatigue resolves
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Assign assistive personnel to perform all self-care tasks for the client
• D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote independence while managing fatigue. This approach allows the client to regain confidence in their abilities and fosters independence. Option A is incorrect as prolonged bed rest can lead to deconditioning and worsen fatigue. Option C is not promoting independence as it involves delegating all self-care tasks to others. Option D involves family assistance, which may be helpful but does not directly promote the client's independence in self-care.

5. A nurse is reinforcing teaching about wound care for a client who has a wound requiring irrigation. What is an important instruction?

• A. Wear sterile gloves when applying a new dressing
• B. Cleanse the wound from the center outwards
• C. Keep the wound dry between dressing changes
• D. Apply an antimicrobial ointment to the wound

Correct answer: B

Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps reduce the risk of contamination by pushing debris away from the wound. Option A, wearing sterile gloves, is important for infection control but not specifically related to wound irrigation. Option C, keeping the wound dry, is not suitable for wound irrigation, which often involves using solutions to clean the wound. Option D, applying an antimicrobial ointment, is not typically done during wound irrigation as the focus is on cleansing the wound.

Similar Questions