Nursing Elites

1. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload?

• A. Low back pain
• B. Dyspnea
• C. Hypotension
• D. Thready pulse

Correct answer: B

Rationale: The correct answer is B: Dyspnea. Dyspnea, or difficulty breathing, is a common sign of fluid overload in a client receiving packed RBCs. When fluid accumulates in the lungs due to overload, it can lead to respiratory distress. This finding requires prompt intervention to prevent further complications. Choices A, C, and D are incorrect: A) Low back pain is not typically associated with fluid overload; C) Hypotension refers to low blood pressure and is not a typical finding in fluid overload; D) Thready pulse may indicate poor perfusion but is not a direct indicator of fluid overload.

2. A nurse is caring for a client who is receiving enteral nutrition via a nasogastric tube. Which of the following actions should the nurse take to reduce the risk of aspiration?

• A. Position the client supine during feedings.
• B. Administer the feedings over 10 minutes.
• C. Elevate the head of the bed during feedings.
• D. Place the client in a lateral position after feedings.

Correct answer: C

Rationale: The correct action to reduce the risk of aspiration in clients receiving enteral feedings is to elevate the head of the bed during feedings. This position helps prevent regurgitation and aspiration of the feeding. Positioning the client supine (Choice A) increases the risk of aspiration as it promotes reflux. Administering feedings over 10 minutes (Choice B) does not directly reduce the risk of aspiration. Placing the client in a lateral position after feedings (Choice D) does not address the risk of aspiration during the feeding process.

3. A client is receiving opioid analgesics for pain management. Which of the following assessments is the priority?

• A. Monitor the client's blood pressure.
• B. Check the client's urinary output.
• C. Monitor the client's respiratory rate.
• D. Assess the client's pain level.

Correct answer: C

Rationale: The correct answer is C: Monitor the client's respiratory rate. When a client is receiving opioid analgesics, the priority assessment is monitoring respiratory rate. Opioids can cause respiratory depression, so it is crucial to assess the client's breathing to detect any signs of respiratory distress promptly. Checking the client's blood pressure (Choice A) and urinary output (Choice B) are important assessments too, but they are not the priority when compared to ensuring adequate respiratory function. Assessing the client's pain level (Choice D) is essential for overall care but is not the priority assessment when the client is on opioids, as respiratory status takes precedence.

4. A nurse is caring for a client who is at risk for pressure ulcers. Which of the following interventions should the nurse implement?

• A. Turn the client every 2 hours
• B. Use a donut-shaped cushion when sitting
• C. Elevate the head of the bed to 45 degrees
• D. Massage reddened areas to increase circulation

Correct answer: A

Rationale: The correct intervention for preventing pressure ulcers in a client at risk is to turn the client every 2 hours. This helps relieve pressure on bony prominences, improving circulation and preventing tissue damage. Using a donut-shaped cushion can actually increase pressure on the skin and worsen the risk of pressure ulcers. Elevating the head of the bed to 45 degrees is beneficial for preventing aspiration in some cases but does not directly address pressure ulcer prevention. Massaging reddened areas can further damage the skin and increase the risk of pressure ulcer development by causing friction and shearing forces.

5. A client has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan?

• A. Cleanse the wound with povidone-iodine solution daily.
• B. Irrigate the wound with hydrogen peroxide.
• C. Reposition the client every 4 hours.
• D. Apply a moisture barrier ointment.

Correct answer: D

Rationale: The correct intervention for a client with a stage 3 pressure injury is to apply a moisture barrier ointment. This helps protect the skin, maintain moisture balance, and promote healing. Choice A is incorrect because povidone-iodine solution can be too harsh for wound care. Choice B is incorrect as hydrogen peroxide can be cytotoxic to healing tissue. Choice C is important for preventing pressure injuries but is not a direct intervention for a stage 3 wound.

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