Nursing Elites

1. A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

• A. Providing care in the hallway
• B. Reporting client information in the hallway
• C. Helping another client use the restroom
• D. Feeding the client too quickly

Correct answer: B

Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.

2. How should a healthcare professional assess and manage a patient with acute renal failure?

• A. Monitor urine output and administer diuretics
• B. Administer IV fluids and restrict potassium intake
• C. Monitor electrolyte levels and provide dietary education
• D. Administer potassium and restrict fluids

Correct answer: A

Rationale: In acute renal failure, it is crucial to monitor urine output to assess kidney function and fluid balance. Administering diuretics helps manage fluid levels by promoting urine production. Choice B is incorrect because administering IV fluids can worsen fluid overload in renal failure patients, and restricting potassium intake is not typically the initial approach. Choice C is not the primary intervention but is important for long-term management. Choice D is incorrect as administering potassium can be dangerous in renal failure, and restricting fluids can lead to dehydration.

3. A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?

• A. I will position the car seat in the front seat
• B. I will secure the car seat in the car by using the seatbelt
• C. I will use a rear-facing car seat
• D. I will install the car seat facing forward

Correct answer: C

Rationale: The correct answer is C. Using a rear-facing car seat is the safest position for a newborn. Newborns should always be placed in a rear-facing car seat in the back seat of the vehicle to provide optimal safety in case of a crash. Choice A is incorrect because placing the car seat in the front seat is not safe due to the presence of airbags. Choice B is incorrect as securing the car seat using the seatbelt is not specific to the correct positioning of the car seat. Choice D is incorrect because installing the car seat facing forward is not recommended for newborns as it does not provide the same level of protection as a rear-facing position.

4. What is the role of a nurse in managing a patient with acute kidney injury (AKI)?

• A. Monitor urine output and electrolyte levels
• B. Administer diuretics and restrict potassium
• C. Provide dietary education and monitor fluid intake
• D. Administer antibiotics and check for dehydration

Correct answer: A

Rationale: The correct answer is A: 'Monitor urine output and electrolyte levels.' In managing a patient with acute kidney injury (AKI), it is crucial for the nurse to monitor urine output and electrolyte levels to assess kidney function and the patient's fluid and electrolyte balance. This monitoring helps in early detection of any worsening kidney function or electrolyte imbalances. Choice B is incorrect because administering diuretics and restricting potassium may not be appropriate for all AKI patients and should be done under the direction of a healthcare provider. Choice C is also incorrect as providing dietary education and monitoring fluid intake are important but do not directly address the immediate management of AKI. Choice D is incorrect as administering antibiotics and checking for dehydration are not primary interventions for managing AKI; antibiotics are only given if there is an infection contributing to AKI, and dehydration should be managed but is not the primary role of the nurse in AKI management.

5. How should a healthcare professional assess a patient with fluid overload?

• A. Monitor weight and assess for edema
• B. Monitor blood pressure and auscultate lung sounds
• C. Assess for jugular venous distention
• D. Monitor oxygen saturation and check for fluid retention

Correct answer: A

Rationale: The correct way to assess a patient with fluid overload is by monitoring weight and assessing for edema. Weight monitoring helps in detecting fluid retention, and edema is a visible sign of excess fluid accumulation. Although monitoring blood pressure and auscultating lung sounds are important assessments in heart failure, they are not specific to fluid overload. Assessing for jugular venous distention is more indicative of right-sided heart failure rather than fluid overload. Monitoring oxygen saturation and checking for fluid retention are not primary assessments for fluid overload.

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