Nursing Elites

1. A healthcare professional is managing a client with a wound infection. What is the priority action?

• A. Change the wound dressing every 12 hours
• B. Perform a wound culture before applying antibiotics
• C. Apply a wet-to-dry dressing to the wound
• D. Cleanse the wound with a solution of alcohol and water

Correct answer: B

Rationale: Performing a wound culture before applying antibiotics is crucial to identify the specific pathogen causing the infection. This helps in selecting the most effective antibiotics for treatment. Changing the wound dressing, applying a wet-to-dry dressing, or cleansing the wound are important interventions but should follow the assessment and identification of the infecting organism through a wound culture to guide appropriate treatment.

2. 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.

3. A client has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the teaching?

• A. Place the tablet under the tongue and wait 10 minutes
• B. Take up to five tablets during an angina episode
• C. Take up to three tablets during a single angina episode
• D. Swallow the tablet with water

Correct answer: C

Rationale: The correct answer is C: 'Take up to three tablets during a single angina episode.' Nitroglycerin can be taken up to three times during an episode to relieve angina. Choice A is incorrect because the client should place the tablet under the tongue and wait for it to dissolve, not wait for 10 minutes. Choice B is incorrect because taking up to five tablets during an angina episode is excessive and not recommended. Choice D is incorrect because nitroglycerin tablets are meant to be taken sublingually, not swallowed.

4. How should a healthcare professional monitor a patient receiving IV potassium?

• A. Monitor ECG for dysrhythmias
• B. Monitor urine output
• C. Monitor serum potassium levels
• D. All of the above

Correct answer: D

Rationale: When a patient is receiving IV potassium, it is crucial to monitor various parameters to ensure patient safety. Monitoring the ECG helps in identifying any potential dysrhythmias that may occur due to potassium imbalances. Monitoring urine output is important as potassium levels can affect renal function. Monitoring serum potassium levels is essential to assess the effectiveness of the IV potassium therapy. Therefore, all the options - monitoring ECG for dysrhythmias, urine output, and serum potassium levels - are necessary when administering IV potassium, making 'All of the above' the correct answer. Choices A, B, and C are not individually sufficient as they each address different aspects of patient monitoring when receiving IV potassium.

5. What is the best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care?

• A. Instruct the client to rest completely and avoid all self-care tasks
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Assign assistive personnel to complete all self-care tasks
• D. Ask the client's family to assist with self-care tasks

Correct answer: B

Rationale: The best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care is to encourage the client to gradually resume self-care tasks with frequent rest periods. This approach helps the client regain independence while managing fatigue effectively. Choice A is incorrect because complete rest without any self-care tasks may hinder recovery and independence. Choice C is not the best option as it does not promote the client's independence. Choice D, while involving family support, does not empower the client to regain self-care abilities.

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