Nursing Elites

1. After a motor vehicle collision, a client is admitted to the medical unit with acute adrenal insufficiency (Addisonian crisis). Which prescription should the nurse implement?

• A. Determine serum glucose levels
• B. Withhold potassium additives to IV fluids
• C. Give IV corticosteroid replacement
• D. Prepare to initiate IV vasopressors

Correct answer: C

Rationale: In a client with acute adrenal insufficiency (Addisonian crisis) following a motor vehicle collision, the priority intervention is to administer IV corticosteroid replacement. This is crucial to manage the crisis by replacing the deficient cortisol. Determining serum glucose levels (Choice A) may be important but is not the immediate priority in this situation. Withholding potassium additives to IV fluids (Choice B) is not indicated and may exacerbate electrolyte imbalances. Initiating IV vasopressors (Choice D) is not the primary treatment for acute adrenal insufficiency and should be reserved for managing hypotension that is unresponsive to corticosteroid therapy.

2. A client has a history of vasovagal attacks resulting in brady-dysrhythmias. Which instruction is most important to include in the teaching plan?

• A. Use stool softeners regularly
• B. Avoid electromagnetic fields
• C. Maintain a low-fat diet
• D. Do not use aspirin products

Correct answer: A

Rationale: The correct answer is A: 'Use stool softeners regularly.' Vasovagal attacks can be triggered by straining, and using stool softeners can help prevent such attacks. Choices B, C, and D are not directly related to preventing vasovagal attacks in this context. Avoiding electromagnetic fields, maintaining a low-fat diet, or not using aspirin products are important for various health reasons but not specifically for preventing vasovagal attacks related to brady-dysrhythmias.

3. A client with diabetes mellitus tells the nurse that she uses cranberry juice to help prevent urinary tract infection. What instruction should the nurse provide?

• A. Ensure to drink sugar-free cranberry juice
• B. Drinking cranberry juice does not prevent infection
• C. Cranberries do not affect insulin levels
• D. Excessive cranberry juice consumption can lead to constipation

Correct answer: B

Rationale: The correct answer is B: Drinking cranberry juice does not prevent urinary tract infections and should not be relied upon as a preventive measure. While cranberry juice is often associated with preventing UTIs, there is limited scientific evidence to support this claim. Choice A is incorrect because the sugar content in cranberry juice is not the main concern when discussing its role in preventing UTIs. Choice C is incorrect as there is no significant evidence to suggest cranberries affecting insulin levels. Choice D is incorrect as constipation is not a typical side effect of consuming cranberry juice; however, excessive consumption may lead to gastrointestinal discomfort.

4. What action should the nurse implement for a female client with cancer who has a good appetite but experiences nausea whenever she smells food cooking?

• A. Encourage family members to cook meals outdoors and bring the cooked food inside
• B. Advise the client to replace cooked foods with a variety of different nutritional supplements
• C. Assess the client’s mucus membranes and report the findings to the healthcare provider
• D. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting

Correct answer: A

Rationale: The correct action for the nurse to implement is to encourage family members to cook meals outdoors and bring the cooked food inside. This strategy can help reduce the smell of cooking food and potentially alleviate the client's nausea triggered by food smells. Assessing the client's mucus membranes (choice C) is not directly related to the client's symptom of nausea triggered by food smells. Instructing the client to take an antiemetic before every meal (choice D) may not address the root cause of the issue, which is the smell of cooking food. Advising the client to replace cooked foods with nutritional supplements (choice B) does not address the immediate problem of food odors triggering nausea.

5. The nurse is demonstrating wound care to a client following abdominal surgery. In what order should the nurse teach the technique?

• A. Remove old dressing using clean gloves. Discard gloves with old dressing
• B. Moisten sterile gauze with normal saline. Clean wound from least contaminated area to most contaminated area
• C. Apply sterile gauze dressing to wound area
• D. Secure dressing with tape

Correct answer: A

Rationale: The correct order ensures proper aseptic technique and wound care to prevent infection. The first step is to remove the old dressing using clean gloves to prevent contamination. Discarding the gloves with the old dressing helps maintain cleanliness. Choices B, C, and D are incorrect because cleaning the wound, applying a new dressing, and securing it should come after removing the old dressing to maintain asepsis and prevent infection.

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