Nursing Elites

1. What is the priority intervention for a patient with fluid overload?

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

Correct answer: A

Rationale: The correct answer is to administer diuretics. Diuretics help reduce excess fluid in cases of fluid overload, making it the priority intervention. Administering additional IV fluids (choice B) would exacerbate the problem by adding more fluid. Providing oral fluids (choice C) is not the priority as the excess fluid needs to be removed first. Chest physiotherapy (choice D) is not the primary intervention for fluid overload.

2. How should a healthcare provider manage a patient who is experiencing acute pain?

• A. Administer analgesics as prescribed
• B. Reposition the patient to alleviate pain
• C. Offer non-pharmacological interventions
• D. Administer IV fluids

Correct answer: A

Rationale: Corrected Rationale: Administering prescribed analgesics is the most effective way to manage acute pain. Analgesics help in reducing or eliminating pain quickly and efficiently. Repositioning the patient may be helpful in certain cases to relieve discomfort, but it is not the primary intervention for managing acute pain. Non-pharmacological interventions can be beneficial as adjuncts to pain management, but in cases of acute pain, administering analgesics is the priority. Administering IV fluids may be necessary for certain conditions but is not the primary intervention for managing acute pain.

3. A nurse is providing discharge teaching to a client who has hypertension about monitoring blood pressure at home. Which of the following instructions should the nurse include?

• A. Use a cuff that is too loose for the arm.
• B. Place the cuff over clothing.
• C. Sit quietly for 5 minutes before measuring your blood pressure.
• D. Use the same arm for each reading.

Correct answer: C

Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before measuring their blood pressure. This allows the body to relax and stabilize, leading to a more accurate reading. Choice A is incorrect because using a cuff that is too loose can result in inaccurate readings. Choice B is incorrect as the cuff should be placed directly on the bare skin. Choice D is incorrect as using the same arm for each reading is important for consistency in monitoring, but sitting quietly before measuring is crucial for accuracy.

4. A nurse is assessing a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 62/min
• B. Blood pressure of 118/78 mm Hg
• C. Respiratory rate of 10/min
• D. Pain rating of 4 on a scale of 0 to 10

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within normal limits and are not indicative of a potentially life-threatening complication associated with morphine therapy.

5. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?

• A. Urine output of 20 ml/hr
• B. Montevideo units consistently at 300 mm Hg
• C. FHR pattern with absent variability
• D. Contractions every 5 minutes that last 30 seconds

Correct answer: D

Rationale: The correct answer is D because contractions every 5 minutes that last 30 seconds indicate that the rate of infusion should be increased. This pattern suggests weak contractions or intervals that are too far apart, requiring an adjustment to improve labor progress. Option A is incorrect as a low urine output is not directly related to the need for an increase in the oxytocin infusion rate. Option B, Montevideo units consistently at 300 mm Hg, is incorrect because it is a measure of intrauterine pressure and does not determine the need for an increase in oxytocin infusion. Option C, FHR pattern with absent variability, is incorrect as it may indicate fetal distress but does not specifically relate to the need for adjusting the oxytocin infusion rate.

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