Nursing Elites

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

• A. Administer calcium gluconate
• B. Administer insulin
• C. Administer sodium bicarbonate
• D. Administer a diuretic

Correct answer: A

Rationale: The correct answer is to administer calcium gluconate. In hyperkalemia, the priority is to protect the heart from potential complications like arrhythmias. Calcium gluconate is the first-line treatment as it stabilizes the cardiac cell membrane. Insulin (Choice B) and sodium bicarbonate (Choice C) can be used in conjunction with other treatments to shift potassium into cells, but calcium gluconate is the priority. Administering a diuretic (Choice D) is not the primary intervention for hyperkalemia and can even worsen the condition by reducing potassium excretion.

2. A nurse is planning care for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?

• A. Fasting blood glucose
• B. Carbohydrate intake
• C. Hematocrit
• D. Weight

Correct answer: D

Rationale: The correct answer is D: Weight. Weight monitoring is essential to assess the effectiveness of desmopressin therapy, as fluid retention is a common side effect. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin therapy for diabetes insipidus. Monitoring carbohydrate intake (choice B) may be important in diabetes management but is not specific to desmopressin therapy. Hematocrit (choice C) monitoring is not a primary concern when managing diabetes insipidus with desmopressin.

3. What is the most appropriate intervention for a patient with confusion post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer IV fluids
• D. Perform a neurological assessment

Correct answer: A

Rationale: Administering oxygen is the most appropriate intervention for a patient with confusion post-surgery because it helps alleviate confusion caused by potential hypoxia. In a post-surgical setting, confusion can be a sign of decreased oxygen levels in the blood due to various reasons such as respiratory depression, decreased lung function, or other complications. Administering oxygen can quickly address hypoxia, improving oxygenation to the brain and reducing confusion. Repositioning the patient, administering IV fluids, or performing a neurological assessment are not the primary interventions for confusion related to hypoxia post-surgery.

4. A nurse is reviewing the medical records of a client who has thrombocytopenia. Which of the following actions should the nurse include in the care plan?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct answer is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, leading to decreased blood clotting ability. Providing a stool softener is essential to prevent constipation and straining during bowel movements, which can lead to bleeding in thrombocytopenic clients. Encouraging the client to floss daily (Choice A) is a good oral hygiene practice but is not directly related to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is important for immunocompromised clients to prevent exposure to pathogens but is not specifically related to thrombocytopenia. Avoiding serving raw vegetables (Choice D) is a precaution to reduce the risk of infection in immunocompromised clients but does not directly address the complications of thrombocytopenia.

5. A client has a new diagnosis of COPD. Which of the following instructions should the nurse include in the teaching?

• A. Breathe rapidly through your mouth when using the incentive spirometer.
• B. Use pursed-lip breathing during periods of dyspnea.
• C. Avoid drinking fluids during meals.
• D. Use diaphragmatic breathing during periods of dyspnea.

Correct answer: B

Rationale: Pursed-lip breathing is a beneficial technique for clients with COPD as it helps control shortness of breath and improves oxygenation. This technique involves inhaling slowly through the nose and exhaling through pursed lips, which helps keep airways open. Option A is incorrect as breathing rapidly through the mouth when using the incentive spirometer can lead to hyperventilation. Option C is incorrect because it is important for clients with COPD to stay hydrated by drinking fluids between meals, but not during meals which can cause bloating and discomfort. Option D is incorrect as diaphragmatic breathing, though beneficial, is not the preferred technique for managing dyspnea in COPD; pursed-lip breathing is more effective.

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