Nursing Elites

1. What is the priority for a client with dehydration?

• A. Administer antiemetics to prevent nausea
• B. Monitor electrolyte levels to prevent imbalances
• C. Administer oral rehydration solutions
• D. Administer intravenous fluids

Correct answer: B

Rationale: The priority for a client with dehydration is to monitor electrolyte levels to prevent imbalances. Dehydration can lead to electrolyte disturbances, which can have serious consequences. Administering antiemetics (Choice A) may help with nausea but does not address the root cause of dehydration. Administering oral rehydration solutions (Choice C) can be beneficial, but monitoring electrolyte levels is crucial in managing dehydration. Administering intravenous fluids (Choice D) is important in severe cases of dehydration, but monitoring electrolytes should come first to assess the extent of the imbalance and guide fluid replacement therapy effectively.

2. A nurse is reinforcing home safety instructions with the parent of a newborn. Which of the following statements should the nurse include in the instructions?

• A. Place your baby's crib away from heat vents
• B. Place the crib close to a heater
• C. Place the crib near a window
• D. Place soft toys in the crib

Correct answer: A

Rationale: The correct answer is A: 'Place your baby's crib away from heat vents.' Placing the crib away from heat vents is essential to prevent the baby from becoming overheated and to reduce the risk of Sudden Infant Death Syndrome (SIDS). Choice B is incorrect because placing the crib close to a heater increases the risk of overheating and poses a fire hazard. Choice C is incorrect as placing the crib near a window exposes the baby to drafts and temperature fluctuations. Choice D is incorrect as soft toys in the crib can pose a suffocation risk to the newborn.

3. What are the signs and symptoms of fluid overload?

• A. Edema, shortness of breath, weight gain
• B. High blood pressure and jugular venous distention
• C. Low blood pressure and cyanosis
• D. Tachycardia and dizziness

Correct answer: A

Rationale: The correct signs and symptoms of fluid overload include edema, shortness of breath, and weight gain. Edema is the abnormal accumulation of fluid causing swelling, shortness of breath can occur due to fluid accumulating in the lungs, and weight gain is often seen as a result of excess fluid retention. Choices B, C, and D are incorrect because high blood pressure and jugular venous distention are more indicative of conditions like heart failure, while low blood pressure and cyanosis are seen in conditions like shock or poor perfusion. Tachycardia and dizziness are not typical signs of fluid overload.

4. What is the priority nursing action for a client with dehydration?

• A. Administer oral fluids
• B. Monitor electrolyte levels
• C. Administer antiemetics as needed
• D. Encourage bed rest

Correct answer: B

Rationale: The priority nursing action for a client with dehydration is to monitor electrolyte levels. Dehydration can cause imbalances in electrolytes such as sodium and potassium, affecting essential bodily functions. Monitoring electrolyte levels is crucial to promptly identify and correct any imbalances. While administering oral fluids (Choice A) is vital in treating dehydration, monitoring electrolyte levels takes precedence as it directly addresses the underlying imbalance. Administering antiemetics (Choice C) may be necessary for nausea and vomiting but is not the priority over electrolyte monitoring. Encouraging bed rest (Choice D) can conserve energy but is not as critical as monitoring electrolyte levels to prevent complications related to electrolyte imbalances.

5. How should a healthcare provider respond to a patient with a suspected pulmonary embolism?

• A. Administer oxygen and call for emergency assistance
• B. Position the patient in a prone position and give fluids
• C. Administer anticoagulants and elevate the patient's legs
• D. Administer thrombolytics and perform chest physiotherapy

Correct answer: A

Rationale: Administering oxygen and calling for emergency assistance are the immediate priorities when managing a suspected pulmonary embolism. Oxygen helps support the patient's respiratory function, while emergency assistance is crucial for further evaluation and treatment. Positioning the patient in a prone position or giving fluids can worsen the condition by impeding blood flow. Administering anticoagulants may be part of the treatment plan but is not the initial response. Thrombolytics and chest physiotherapy are not first-line treatments for suspected pulmonary embolism and can even be harmful without prior evaluation.

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