Nursing Elites

1. A client with Addison's disease becomes confused and weak. What is the nurse's first action?

• A. Administer a dose of hydrocortisone immediately.
• B. Check the client’s electrolyte levels.
• C. Administer a dose of normal saline.
• D. Measure the client’s blood pressure in both arms.

Correct answer: A

Rationale: The correct answer is to administer a dose of hydrocortisone immediately. In Addison's disease, confusion and weakness can be signs of an adrenal crisis. Administering hydrocortisone promptly is crucial to prevent further deterioration. Checking electrolyte levels (Choice B) is important but not the first action in managing an acute adrenal crisis. Administering normal saline (Choice C) is not the priority in this situation. Measuring blood pressure in both arms (Choice D) is not the initial action needed to address the client's confusion and weakness in Addison's disease.

2. A client with hypertension is prescribed a beta-blocker. What teaching should the nurse provide about this medication?

• A. Instruct the client to avoid high-potassium foods.
• B. Monitor the client’s heart rate and report any bradycardia.
• C. Advise the client to rise slowly from a sitting or lying position.
• D. Instruct the client to avoid sudden position changes.

Correct answer: C

Rationale: The correct answer is to advise the client to rise slowly from a sitting or lying position. Beta-blockers can cause bradycardia and hypotension, so clients should be advised to rise slowly to prevent dizziness and falls. Monitoring the client's heart rate and blood pressure regularly is essential. Instructing the client to avoid high-potassium foods (Choice A) is not directly related to beta-blockers. While monitoring the client's heart rate (Choice B) is important, advising the client to rise slowly (Choice C) is more directly related to potential side effects of beta-blockers. Instructing the client to avoid sudden position changes (Choice D) is not as specific or essential as advising them to rise slowly to prevent adverse effects.

3. A client with atrial fibrillation is prescribed warfarin, and their INR is elevated. What is the nurse's priority action?

• A. Administer a dose of vitamin K to reverse the effects of warfarin.
• B. Monitor the client for signs of bleeding, such as bruising or nosebleeds.
• C. Increase the client’s warfarin dosage to prevent clot formation.
• D. Notify the healthcare provider immediately and hold the next dose of warfarin.

Correct answer: D

Rationale: An elevated INR in clients taking warfarin increases the risk of bleeding, indicating the dose may be too high. The nurse's priority action is to notify the healthcare provider immediately and hold the next dose of warfarin to prevent bleeding complications. Administering vitamin K is not the first-line intervention for an elevated INR. Monitoring for signs of bleeding is important but not the priority over contacting the healthcare provider. Increasing the warfarin dosage can exacerbate the risk of bleeding and is contraindicated.

4. A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give the child sugar water only.
• B. Offer oral rehydration solution every 2 hours.
• C. Provide Pedialyte feedings via nasogastric tube.
• D. Maintain intravenous fluid therapy per prescription.

Correct answer: D

Rationale: The correct intervention for a 5-week-old infant diagnosed with hypertrophic pyloric stenosis and experiencing projectile vomiting is to maintain intravenous fluid therapy. Intravenous fluids are crucial for rehydrating an infant suffering from dehydration due to rapid fluid loss from vomiting. Instructing the mother to provide sugar water only (choice A) is inappropriate and insufficient for rehydration. Offering oral rehydration solution every 2 hours (choice B) may not be effective if the infant continues to vomit. Providing Pedialyte feedings via nasogastric tube (choice C) may also not be as effective as intravenous fluid therapy in rapidly replenishing fluids and stabilizing the child's condition.

5. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is?

• A. Difference in the intake and output
• B. Changes in the mucous membranes
• C. Skin turgor
• D. Weekly weight

Correct answer: D

Rationale: In clients with altered renal function being treated at home, weekly weight is the most accurate indicator of fluid balance. Fluid retention or loss can significantly affect weight, making it a reliable measure. Choices A, B, and C are not as accurate indicators of fluid balance as weekly weight. Intake and output differences can vary in accuracy and may not capture all aspects of fluid balance. Changes in mucous membranes and skin turgor can be influenced by factors other than fluid balance, making them less precise indicators.

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