Nursing Elites

1. A client is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions?

• A. Supine with head elevated
• B. Lateral recumbent
• C. Prone with arms at sides
• D. Sitting with back rounded

Correct answer: B

Rationale: The correct position for a lumbar puncture is the lateral recumbent position. This position allows the spine to curve naturally, widening the spaces between the vertebrae, making it easier and safer to perform the procedure. Supine with head elevated (Choice A) would not provide the proper positioning for a lumbar puncture as it does not allow for proper access to the lumbar area. Prone with arms at sides (Choice C) would not be suitable as it would not facilitate the procedure. Sitting with back rounded (Choice D) is also incorrect as it does not allow for the proper alignment of the spine needed for a lumbar puncture.

2. What is the most important intervention when managing a client with delirium?

• A. Administer a sedative to reduce agitation
• B. Identify any reversible causes of delirium
• C. Increase environmental stimulation
• D. Limit noise and provide a calm environment

Correct answer: B

Rationale: The correct answer is B: 'Identify any reversible causes of delirium.' When managing a client with delirium, it is crucial to first identify and address any reversible factors contributing to the delirium. Administering sedatives (Choice A) may worsen delirium and is not the primary intervention. Increasing environmental stimulation (Choice C) can exacerbate symptoms. Limiting noise and providing a calm environment (Choice D) are beneficial but not as crucial as identifying reversible causes.

3. A patient took an overdose of acetaminophen. Which of the following medications should the nurse plan to administer to the patient?

• A. Naloxone
• B. Acetylcysteine
• C. Flumazenil
• D. Activated charcoal

Correct answer: B

Rationale: Acetylcysteine is the antidote for acetaminophen overdose. It works by replenishing glutathione, a key component in detoxifying acetaminophen metabolites, thus preventing liver damage. Naloxone is used to reverse opioid overdose, not acetaminophen. Flumazenil is a benzodiazepine antidote. Activated charcoal is used to limit absorption in cases of poisoning, but it is not the antidote for acetaminophen overdose.

4. Which intervention should be included for a client with heart failure?

• A. Encourage increased fluid intake
• B. Weigh the client daily to monitor fluid balance
• C. Restrict fluid intake during meals
• D. Limit daily activity to prevent fatigue

Correct answer: B

Rationale: Weighing the client daily to monitor fluid balance is crucial for clients with heart failure. This intervention helps assess for fluid retention or depletion, providing valuable information for managing the condition effectively. Encouraging increased fluid intake (Choice A) is contraindicated in heart failure as it can worsen fluid overload. Restricting fluid intake during meals (Choice C) may lead to dehydration, which is harmful for clients with heart failure. Limiting daily activity (Choice D) is not recommended as appropriate activity levels should be encouraged for overall well-being, under guidance to prevent excessive fatigue.

5. What are the differences between Type 1 and Type 2 diabetes in terms of treatment?

• A. Type 1: Insulin therapy; Type 2: Lifestyle modifications and oral agents
• B. Type 1: Oral agents; Type 2: Insulin therapy
• C. Type 1: Insulin resistance; Type 2: Insulin deficiency
• D. Type 1: Exercise and diet; Type 2: Insulin only

Correct answer: A

Rationale: The correct answer is A because Type 1 diabetes necessitates insulin therapy, whereas Type 2 diabetes is managed with lifestyle modifications and oral agents. Choice B is incorrect because Type 1 diabetes does not use oral agents as a primary treatment. Choice C is incorrect as it describes the pathophysiology of diabetes types rather than their treatments. Choice D is incorrect because Type 2 diabetes management involves more than just insulin and includes lifestyle changes and oral medications.

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