Nursing Elites

1. What is the most important nursing intervention for a patient with diarrhea?

• A. Encourage the patient to increase fluid intake.
• B. Monitor the patient's skin integrity.
• C. Check the patient's electrolyte levels.
• D. Educate the patient about infection control measures.

Correct answer: B

Rationale: The correct answer is to monitor the patient's skin integrity. This is crucial because diarrhea can lead to skin breakdown due to frequent bowel movements and increased moisture in the perineal area. By monitoring skin integrity, nurses can prevent skin breakdown, infection, and other associated issues. Encouraging fluid intake (Choice A) is important but not the most critical intervention. Checking electrolyte levels (Choice C) is essential but may not be the top priority at the onset. Educating the patient about infection control (Choice D) is important but secondary to preventing skin breakdown in a patient with diarrhea.

2. While providing care to a group of patients, which patient should the nurse see first?

• A. A patient after knee surgery who needs range of motion exercises
• B. A patient on bed rest who has renal calculi and needs to go to the bathroom
• C. A bedridden patient who has a reddened area on the buttocks who needs to be turned
• D. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea

Correct answer: D

Rationale: The nurse should see the patient with a hip replacement experiencing chest pain and dyspnea first because these symptoms could indicate a pulmonary embolism, which is a life-threatening condition requiring immediate attention. The other patients also need care, but urgent assessment and intervention are crucial in the case of potential pulmonary embolism to prevent serious complications or death.

3. A client has a new prescription for beclomethasone inhaler to use with an albuterol inhaler for asthma maintenance. What should the nurse instruct the client?

• A. Skip doses if breathing improves
• B. Use the albuterol inhaler first
• C. Gargle with water after each use
• D. Store inhaler in the refrigerator

Correct answer: C

Rationale: The correct answer is to instruct the client to gargle with water after each use of the beclomethasone inhaler. Beclomethasone can cause oral thrush, and gargling with water helps prevent this complication. Choice A is incorrect because the client should not skip doses even if breathing improves, as the medications are prescribed for maintenance. Choice B is incorrect as there is no specific instruction to use the albuterol inhaler first in this scenario. Choice D is incorrect because inhalers should not be stored in the refrigerator unless specified by the manufacturer.

4. A healthcare provider is caring for a client who has heart failure and is prescribed enalapril. The provider should monitor the client for which of the following adverse effects?

• A. Hypertension
• B. Hypokalemia
• C. Hyperglycemia
• D. Hyperkalemia

Correct answer: D

Rationale: Corrected Question: When a client with heart failure is prescribed enalapril, monitoring for hyperkalemia is essential. Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can lead to an increase in potassium levels in the blood. This adverse effect can be serious and potentially life-threatening. Choices A, B, and C are incorrect because enalapril does not typically cause hypertension, hypokalemia, or hyperglycemia as adverse effects. It's essential for healthcare providers to be vigilant in monitoring potassium levels when clients are on ACE inhibitors like enalapril.

5. When administering IV fluids to a dehydrated patient, what is the nurse's priority assessment?

• A. Monitor the patient's electrolyte levels.
• B. Assess the patient's blood pressure regularly.
• C. Monitor the patient's heart rate every 4 hours.
• D. Check the patient's urine output hourly.

Correct answer: B

Rationale: The correct answer is to assess the patient's blood pressure regularly. Monitoring blood pressure is crucial when administering IV fluids to a dehydrated patient as it helps in evaluating the patient's fluid status. Changes in blood pressure can indicate the effectiveness of the fluid therapy, the patient's response to treatment, and the possibility of complications such as fluid overload or hypovolemia. Monitoring electrolyte levels (Choice A) is essential but not the priority when assessing a dehydrated patient receiving IV fluids. Heart rate (Choice C) should be monitored more frequently than every 4 hours in such a situation. Checking urine output (Choice D) is important but not as critical as assessing blood pressure in this scenario.

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