Nursing Elites

1. What is the most important nursing intervention for a patient with a suspected pulmonary embolism?

• A. Administer anticoagulants
• B. Administer oxygen
• C. Reposition the patient
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The most important nursing intervention for a patient with a suspected pulmonary embolism is to administer anticoagulants. Anticoagulants help prevent further clot formation in the patient's blood vessels, reducing the risk of complications such as worsening of the pulmonary embolism or development of new clots. Administering oxygen (Choice B) may be necessary to support the patient's oxygenation, but anticoagulants take precedence as they target the underlying cause of the pulmonary embolism. Repositioning the patient (Choice C) and monitoring oxygen saturation (Choice D) are important aspects of patient care but are not the primary intervention for a suspected pulmonary embolism.

2. A client is taking sucralfate. Which of the following client statements indicates an understanding of the teaching?

• A. I should take this medication 1 hour before meals.
• B. I should take this medication 30 minutes after meals.
• C. I should take this medication only when I have symptoms of heartburn.
• D. I should take this medication with a glass of milk.

Correct answer: A

Rationale: The correct answer is A. Sucralfate is most effective when taken 1 hour before meals to protect the stomach lining. Option B is incorrect because sucralfate should not be taken after meals. Option C is incorrect because sucralfate is typically taken on a regular schedule, not just when symptoms occur. Option D is incorrect because sucralfate should not be taken with milk, as it can interfere with its effectiveness.

3. Which electrolyte imbalance should be closely monitored in patients on furosemide?

• A. Hypokalemia
• B. Hyponatremia
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss in the body, resulting in hypokalemia. Monitoring potassium levels is crucial in patients on furosemide to prevent complications such as cardiac arrhythmias and muscle weakness. Choice B, hyponatremia, is not typically associated with furosemide use. Hyperkalemia (choice C) and hypercalcemia (choice D) are not commonly linked to furosemide therapy; therefore, they are incorrect choices.

4. A nurse is planning care for a client who has a closed head injury and has an intraventricular catheter. Which of the following interventions should the nurse include to reduce the risk for infection?

• A. Keep the head of the bed elevated to 30 degrees.
• B. Administer IV antibiotics prophylactically.
• C. Change the catheter insertion site every 24 hours.
• D. Monitor the insertion site for redness.

Correct answer: D

Rationale: The correct answer is to monitor the insertion site for redness. This intervention helps detect signs of infection early in clients with intraventricular catheters. Keeping the head of the bed elevated to 30 degrees is important for managing intracranial pressure but does not directly reduce the risk of infection. Administering IV antibiotics prophylactically is not recommended as a routine practice due to the risk of antibiotic resistance and should only be done based on culture results. Changing the catheter insertion site every 24 hours is unnecessary and increases the risk of introducing new pathogens.

5. A nurse is assessing a client who has chronic heart failure. Which of the following findings indicates that the client is experiencing fluid overload?

• A. Increased urine output
• B. Bounding peripheral pulses
• C. Weight loss
• D. Decreased heart rate

Correct answer: B

Rationale: In clients with chronic heart failure, bounding peripheral pulses are a classic sign of fluid overload. This occurs due to increased volume in the arterial system, causing a forceful pulse. Increased urine output (Choice A) is often seen in clients with fluid volume deficit, not overload. Weight loss (Choice C) is also inconsistent with fluid overload as it suggests a fluid deficit. Decreased heart rate (Choice D) is more commonly associated with conditions like bradycardia, hypothyroidism, or the use of certain medications, but not specifically indicative of fluid overload in chronic heart failure.

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