Nursing Elites

1. What is an early sign that suctioning is needed for a client with a tracheostomy?

• A. Bradycardia
• B. Irritability
• C. Hypotension
• D. Decreased oxygen saturation

Correct answer: B

Rationale: Irritability is an early sign that suctioning is needed for a client with a tracheostomy. When secretions accumulate in the airway, it can lead to discomfort and irritability in the client. Bradycardia, hypotension, and decreased oxygen saturation are usually later signs of inadequate airway clearance and oxygenation. Bradycardia may indicate severe hypoxia, while hypotension and decreased oxygen saturation are consequences of prolonged airway obstruction.

2. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?

• A. Position the client supine.
• B. Prepare an IV bolus of dextrose 5% in water.
• C. Administer methylergonovine IM.
• D. Administer calcium gluconate IV.

Correct answer: D

Rationale: In cases of magnesium sulfate toxicity, calcium gluconate is the antidote that should be administered promptly. Positioning the client supine (Choice A) is not the priority in this scenario. Administering dextrose 5% in water (Choice B) is not indicated for magnesium sulfate toxicity. Methylergonovine IM (Choice C) is used for postpartum hemorrhage, not for magnesium sulfate toxicity.

3. Which nursing intervention is essential for a client diagnosed with heart failure?

• A. Encourage fluid intake to prevent dehydration
• B. Monitor the client's weight daily to assess fluid balance
• C. Increase sodium intake to prevent fluid retention
• D. Limit fluid intake to avoid overload

Correct answer: B

Rationale: The correct answer is to monitor the client's weight daily to assess fluid balance in clients with heart failure. This intervention helps healthcare providers evaluate fluid retention or loss, which is crucial in managing heart failure. Choice A is incorrect because excessive fluid intake can worsen heart failure symptoms by causing fluid overload. Choice C is incorrect because increasing sodium intake can lead to fluid retention, exacerbating heart failure. Choice D is incorrect as limiting fluid intake excessively can also be harmful in heart failure management, potentially leading to dehydration.

4. Which of the following is the best strategy for managing dehydration in a client?

• A. Encourage the client to drink more water
• B. Monitor fluid and electrolyte levels frequently
• C. Administer oral rehydration solutions
• D. Increase the IV fluid rate

Correct answer: B

Rationale: The best strategy for managing dehydration in a client is to monitor fluid and electrolyte levels frequently. This allows healthcare providers to assess the client's hydration status accurately and make informed decisions regarding treatment. Encouraging the client to drink more water (Choice A) may not be sufficient if the dehydration is severe and requires specific interventions. Administering oral rehydration solutions (Choice C) can be beneficial but should be guided by monitoring the client's condition. Increasing the IV fluid rate (Choice D) may be necessary in certain cases, but it is not always the initial or best approach, as monitoring is crucial to avoid fluid and electrolyte imbalances.

5. While caring for a client with an IV infusion who develops redness and warmth at the IV site, what is the most appropriate intervention?

• A. Elevate the IV site and apply an ice pack
• B. Administer an anti-inflammatory medication
• C. Apply a cold compress to the IV site
• D. Discontinue the IV and notify the provider

Correct answer: D

Rationale: The correct intervention when a client develops redness and warmth at the IV site, indicating phlebitis, is to discontinue the IV and notify the provider. This is crucial to prevent further complications. Elevating the IV site and applying an ice pack (Choice A) may not address the underlying issue of phlebitis. Administering an anti-inflammatory medication (Choice B) is not the primary intervention for phlebitis. Applying a cold compress (Choice C) may provide temporary relief but does not address the need to discontinue the IV when phlebitis occurs.

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