Nursing Elites

1. When assessing a client with signs of delirium, which factor should be the nurse's priority in determining the cause?

• A. Medication history
• B. Fluid and electrolyte imbalances
• C. Psychosocial stressors
• D. Environmental factors

Correct answer: B

Rationale: When a nurse assesses a client with signs of delirium, the priority in determining the cause should be focusing on fluid and electrolyte imbalances. Delirium can often be linked to imbalances in these essential elements, making it crucial to address them promptly. While medication history, psychosocial stressors, and environmental factors can also contribute to delirium, they should be assessed after addressing fluid and electrolyte imbalances due to their immediate impact on cognitive function.

2. What are the key interventions in managing a patient with diabetic ketoacidosis (DKA)?

• A. Administer insulin and fluids
• B. Administer oral hypoglycemics
• C. Administer glucagon
• D. Administer insulin and monitor blood glucose

Correct answer: A

Rationale: The correct intervention in managing a patient with diabetic ketoacidosis (DKA) is to administer insulin and fluids. Insulin is crucial to correct hyperglycemia, while fluids are important to address dehydration. Administering oral hypoglycemics (Choice B) is not appropriate in the management of DKA as the patient may not be able to absorb oral medications due to gastrointestinal issues. Glucagon (Choice C) is not indicated in the treatment of DKA. Although monitoring blood glucose (Choice D) is important, it is not the sole key intervention for managing DKA; administering insulin and fluids are the primary interventions.

3. What are the key signs of respiratory distress?

• A. Increased respiratory rate and use of accessory muscles
• B. Decreased respiratory rate and cyanosis
• C. Cyanosis and use of accessory muscles
• D. Altered mental status and bradycardia

Correct answer: A

Rationale: The correct answer is A: Increased respiratory rate and use of accessory muscles are key signs of respiratory distress. When a person is experiencing respiratory distress, their respiratory rate typically increases as the body tries to compensate for the inadequate oxygenation. Additionally, the use of accessory muscles indicates that the person is working harder to breathe. Choices B, C, and D are incorrect because they do not accurately represent the key signs of respiratory distress. A decreased respiratory rate, cyanosis, altered mental status, and bradycardia are not typical signs of respiratory distress.

4. What is the most appropriate next step when a client with an NG tube attached to low suctioning becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions?

• A. Increase the suction pressure
• B. Irrigate the NG tube with sterile water
• C. Turn the client on their side
• D. Replace the NG tube with a new one

Correct answer: B

Rationale: The correct answer is to irrigate the NG tube with sterile water. When a client with an NG tube attached to low suctioning becomes nauseated and there is a decrease in the flow of gastric secretions, it indicates a possible blockage in the tube. Irrigating the tube with sterile water can help clear the blockage, allowing for proper suctioning and relieving the client's nausea. Increasing the suction pressure (Choice A) can further worsen the issue by potentially causing harm to the client. Turning the client on their side (Choice C) may not address the underlying problem of tube blockage. Replacing the NG tube with a new one (Choice D) should only be considered if other interventions, like irrigation, fail to clear the blockage.

5. What is the appropriate intervention for a patient experiencing hypovolemic shock?

• A. Administer IV fluids
• B. Monitor blood pressure
• C. Place the patient in Trendelenburg position
• D. Administer oxygen

Correct answer: A

Rationale: The correct intervention for a patient experiencing hypovolemic shock is to administer IV fluids. In hypovolemic shock, there is a significant loss of circulating blood volume leading to inadequate perfusion to tissues. Administering IV fluids is crucial to restore blood volume and improve tissue perfusion. Monitoring blood pressure (choice B) is important but not the primary intervention in hypovolemic shock. Placing the patient in Trendelenburg position (choice C) can worsen outcomes by increasing intracranial pressure and is no longer recommended. Administering oxygen (choice D) is beneficial for many conditions but does not address the underlying issue of inadequate circulating blood volume in hypovolemic shock.

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