Nursing Elites

1. A patient is experiencing shortness of breath. What is the nurse's immediate action?

• A. Assist the patient into a high Fowler's position.
• B. Administer oxygen at 2 liters per minute via nasal cannula.
• C. Encourage the patient to take deep breaths and cough.
• D. Assess the patient's lung sounds.

Correct answer: B

Rationale: Administering oxygen at 2 liters per minute via nasal cannula is the immediate action for a patient experiencing shortness of breath. This intervention helps to improve oxygenation and relieve respiratory distress promptly. Placing the patient in a high Fowler's position (choice A) may also be beneficial but providing oxygen takes precedence in this scenario to address the underlying hypoxemia. Encouraging deep breaths and coughing (choice C) may not be appropriate as the first action, especially without assessing the patient first. Assessing lung sounds (choice D) is essential but should follow the initial intervention of administering oxygen.

2. A patient is prescribed a diuretic for hypertension. What is the most important assessment the nurse should perform?

• A. Monitor the patient's respiratory rate.
• B. Check the patient's blood pressure regularly.
• C. Monitor the patient's potassium levels.
• D. Monitor the patient's sodium levels.

Correct answer: D

Rationale: Corrected Rationale: When a patient is prescribed a diuretic for hypertension, monitoring the patient's sodium levels is crucial. Diuretics can lead to alterations in sodium levels, potentially causing complications like hyponatremia. While monitoring other parameters like respiratory rate, blood pressure, and potassium levels may also be important, the primary concern with diuretic therapy is the risk of sodium imbalance, making the monitoring of sodium levels the most critical assessment.

3. A patient with a urinary catheter reports discomfort. What is the nurse's priority action?

• A. Ensure the catheter tubing is not kinked.
• B. Irrigate the catheter to relieve the discomfort.
• C. Change the catheter to a smaller size.
• D. Remove the catheter and replace it with a new one.

Correct answer: A

Rationale: The correct answer is to ensure the catheter tubing is not kinked. This is the priority action because a kinked tubing can obstruct urine flow, leading to discomfort and potential complications. It is essential to troubleshoot the current catheter first before considering other interventions. Irrigating the catheter (Choice B) may not address the underlying issue of kinking. Changing the catheter to a smaller size (Choice C) or removing and replacing it with a new one (Choice D) should only be considered if ensuring the tubing is unkinked does not resolve the discomfort.

4. What are the common side effects of opioid analgesics, and how should they be managed?

• A. Drowsiness and dizziness, ensuring safety precautions
• B. Respiratory depression, ensuring adequate ventilation
• C. Constipation and nausea, managed with stool softeners
• D. Nausea and vomiting, managing with antiemetics

Correct answer: A

Rationale: The correct answer is A. Common side effects of opioid analgesics include drowsiness and dizziness. These side effects can impair a person's ability to operate machinery or drive safely. To manage these side effects, it is essential to advise patients to avoid activities that require alertness until they know how the medication affects them. Choices B, C, and D are incorrect because respiratory depression, constipation, and nausea are also common side effects of opioids, but they are not the primary side effects being asked for in this question.

5. A healthcare professional is assessing a patient's fluid balance. What is the most reliable indicator of fluid status?

• A. Monitor the patient's vital signs.
• B. Check the patient's weight daily.
• C. Measure the patient's intake and output.
• D. Monitor the patient's urine color.

Correct answer: B

Rationale: Checking the patient's weight daily is the most reliable indicator of fluid status because weight changes can directly reflect fluid retention or loss. Monitoring vital signs (Choice A) can provide some information but is not as specific as weight changes. Measuring intake and output (Choice C) is crucial but may not always accurately reflect fluid balance. Monitoring urine color (Choice D) can give some insights into hydration levels, but it is not as reliable as daily weight checks for assessing overall fluid status.

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