Nursing Elites

1. What is the primary intervention for a patient with a pneumothorax?

• A. Insert a chest tube
• B. Administer oxygen
• C. Monitor respiratory rate
• D. Administer analgesics

Correct answer: A

Rationale: The correct answer is to insert a chest tube. This intervention is considered the definitive treatment for a pneumothorax as it helps remove air or fluid from the pleural space, re-expanding the lung. Administering oxygen (Choice B) can be supportive but is not the primary intervention to treat a pneumothorax. Monitoring respiratory rate (Choice C) is important but does not address the underlying issue of air in the pleural space. Administering analgesics (Choice D) may help manage pain but does not treat the pneumothorax itself.

2. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

• A. Increased speech
• B. Lack of sleep
• C. Agitation
• D. Poor concentration

Correct answer: B

Rationale: The correct answer is lack of sleep (choice B). In acute mania, lack of sleep can exacerbate symptoms, lead to exhaustion, and pose serious risks to the client's well-being. Addressing the client's sleep deprivation is a priority as it can impact their overall health and recovery. Increased speech (choice A) and agitation (choice C) are common in acute mania but do not pose immediate physical risks like lack of sleep. Poor concentration (choice D) is also a symptom of acute mania but addressing sleep deprivation takes precedence due to its severe consequences.

3. 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.

4. A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values?

• A. Serum glucose level.
• B. Serum calcium level.
• C. Lymphocyte count.
• D. Serum potassium level.

Correct answer: A

Rationale: The correct answer is A: Serum glucose level. In Cushing's disease, there is an excess production of cortisol, leading to hyperglycemia. This results in an increase in serum glucose levels. Choices B, C, and D are incorrect because Cushing's disease does not directly affect serum calcium levels, lymphocyte count, or serum potassium levels.

5. A client is postoperative following hip replacement surgery. Which of the following instructions should the nurse include in preventing dislocation of the prosthesis?

• A. Cross your legs at the knees
• B. Avoid bending your hip more than 90 degrees
• C. Sit with your legs elevated
• D. Avoid placing a pillow under your knees

Correct answer: B

Rationale: To prevent dislocation of the prosthesis after hip replacement surgery, it is essential to avoid bending the hip more than 90 degrees. This precaution helps maintain the stability of the hip joint and reduces the risk of prosthesis dislocation. Crossing legs at the knees (Choice A) can increase pressure on the hip joint, leading to instability. Sitting with legs elevated (Choice C) and avoiding placing a pillow under the knees (Choice D) do not directly address the risk of prosthesis dislocation.

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