Nursing Elites

1. A client who experienced an acute myocardial infarction expresses concern about fatigue. What is the best strategy to promote self-care?

• A. Ask family members to assist with all self-care tasks
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Instruct the client to remain in bed until fully rested
• D. Assign assistive personnel to complete self-care tasks for the client

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote self-care for a client who experienced an acute myocardial infarction and is experiencing fatigue. This approach helps the client regain independence while managing fatigue. Asking family members to assist with all self-care tasks (Choice A) may hinder the client's independence. Instructing the client to remain in bed until fully rested (Choice C) may lead to deconditioning and dependency. Assigning assistive personnel to complete self-care tasks for the client (Choice D) does not empower the client to regain independence or actively participate in self-care.

2. What are the potential complications of a patient receiving hemodialysis?

• A. Infection and hypotension
• B. Pulmonary embolism and fluid overload
• C. Blood clot formation and electrolyte imbalance
• D. Low blood pressure and nausea

Correct answer: A

Rationale: Corrected Question: What are the potential complications of a patient receiving hemodialysis? Rationale: Infection and hypotension are common complications in patients undergoing hemodialysis. Pulmonary embolism and fluid overload (Choice B) are less common complications associated with hemodialysis. Blood clot formation and electrolyte imbalance (Choice C) are also potential complications but are not as common as infection and hypotension. Low blood pressure and nausea (Choice D) can occur but are not as prevalent as infection and hypotension.

3. A nurse is collecting data from a school-age child who has sustained a skull fracture. Which of the following is a manifestation of increased intracranial pressure?

• A. Nausea
• B. Confusion about own name
• C. Rapid pulse
• D. Vomiting

Correct answer: B

Rationale: Confusion, especially about one's own name, is a sign of increased intracranial pressure and should be addressed. Nausea and vomiting are common symptoms of increased intracranial pressure, but confusion about personal information is a more specific and critical indication that requires immediate attention. Rapid pulse may be a possible response to increased intracranial pressure, but it is not as specific as confusion about own name in this scenario.

4. A client has an NG tube that needs irrigation every 8 hours. Which solution should be used to irrigate the tube to maintain fluid and electrolyte balance?

• A. Tap water
• B. Sterile water
• C. 0.9% sodium chloride
• D. 0.45% sodium chloride

Correct answer: C

Rationale: The correct answer is 0.9% sodium chloride. This solution is isotonic and helps maintain electrolyte balance during irrigation, preventing fluid and electrolyte imbalances. Tap water (choice A) may cause electrolyte imbalances due to its hypotonic nature. Sterile water (choice B) is hypotonic and can lead to electrolyte disturbances. 0.45% sodium chloride (choice D) is hypotonic and may also disrupt electrolyte balance when used for irrigation.

5. A healthcare professional is reviewing the medical record of a client who is receiving furosemide. Which of the following laboratory values should the healthcare professional monitor while the client is taking this medication?

• A. Sodium
• B. Glucose
• C. Potassium
• D. Calcium

Correct answer: C

Rationale: The correct answer is C: Potassium. Furosemide is a diuretic that can cause potassium depletion due to increased urinary excretion. Monitoring potassium levels is crucial to prevent hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Sodium (choice A) levels are not typically affected by furosemide. Glucose (choice B) monitoring is important with other medications like corticosteroids but is not directly related to furosemide use. Calcium (choice D) levels are not significantly impacted by furosemide.

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