Nursing Elites

1. How should a healthcare professional assess a patient with a suspected infection?

• A. Monitor temperature and check for elevated white blood cells
• B. Monitor blood pressure and check for fever
• C. Assess for changes in mental status and monitor urine output
• D. Administer antibiotics and monitor for changes in mental status

Correct answer: A

Rationale: When assessing a patient with a suspected infection, it is crucial to monitor temperature and check for elevated white blood cells. Elevated temperature indicates a potential infection, and increased white blood cells are a sign of inflammation and the body's response to an infection. Monitoring blood pressure (choice B) and checking for fever (choice B) are not as specific indicators of infection as monitoring temperature and white blood cell count. Assessing changes in mental status and monitoring urine output (choice C) are important aspects of patient assessment but may not directly indicate a suspected infection. Administering antibiotics (choice D) should only be done after a confirmed diagnosis of a bacterial infection, as unnecessary antibiotic use can lead to antibiotic resistance and other adverse effects.

2. A nurse is caring for a client who has coronary artery disease (CAD) and is receiving aspirin therapy. Which of the following findings should the nurse report to the provider?

• A. History of gastrointestinal bleeding
• B. Prothrombin time of 12 seconds
• C. Platelet count of 180,000/mm³
• D. Creatinine level of 1.0 mg/dL

Correct answer: A

Rationale: The correct answer is A: History of gastrointestinal bleeding. Aspirin therapy is contraindicated in clients with a history of gastrointestinal bleeding because aspirin can further increase the risk of bleeding. Option B, prothrombin time of 12 seconds, is within the normal range and does not indicate a concern related to aspirin therapy. Option C, platelet count of 180,000/mm³, is also within the normal range and does not suggest a need for reporting to the provider in the context of aspirin therapy. Option D, creatinine level of 1.0 mg/dL, is within the normal range and is not directly related to aspirin therapy in this scenario.

3. What are the key signs of hyperkalemia and how should it be treated?

• A. Elevated potassium levels, muscle weakness; administer calcium gluconate
• B. Decreased potassium levels, confusion; administer potassium chloride
• C. Elevated sodium levels, bradycardia; administer sodium bicarbonate
• D. Low sodium levels, muscle cramps; administer sodium chloride

Correct answer: A

Rationale: The correct signs of hyperkalemia include elevated potassium levels and muscle weakness. The treatment involves administering calcium gluconate to help stabilize the heart. Choice B is incorrect as hyperkalemia is characterized by elevated, not decreased, potassium levels. Choice C is incorrect as hyperkalemia does not involve elevated sodium levels, and the treatment is not sodium bicarbonate. Choice D is incorrect as hyperkalemia does not lead to low sodium levels, and sodium chloride is not the treatment for hyperkalemia.

4. After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?

• A. Irrigate the nasogastric tube with distilled water
• B. Aspirate the gastric contents with a syringe
• C. Administer an antiemetic medication
• D. Insert a new nasogastric tube

Correct answer: B

Rationale: The most appropriate nursing intervention when a client with a nasogastric tube experiences nausea and a decrease in gastric secretions is to aspirate the gastric contents with a syringe. This action helps relieve nausea by removing excess fluid and gas. Option A, irrigating the nasogastric tube with distilled water, is not indicated as it does not address the underlying issue of decreased gastric secretions. Option C, administering an antiemetic medication, may provide symptomatic relief but does not address the mechanical issue of decreased flow in the nasogastric tube. Option D, inserting a new nasogastric tube, is not necessary unless there are specific complications or obstructions in the current tube.

5. How should a healthcare professional assess and manage a patient with delirium?

• A. Assess for confusion and reorient the patient
• B. Provide a quiet environment and administer sedatives
• C. Provide oxygen therapy and monitor vital signs
• D. Provide pain relief and monitor for signs of recovery

Correct answer: A

Rationale: The correct way to assess and manage a patient with delirium is by assessing for confusion and reorienting the patient. Delirium is characterized by acute confusion and disturbance in attention, so reorienting the patient to time, place, and person can help improve their awareness and cognition. Providing a quiet environment is important to reduce stimuli that can exacerbate delirium, but administering sedatives may worsen the condition. Oxygen therapy and monitoring vital signs are essential aspects of general patient care but are not specific to managing delirium. Providing pain relief is important for overall patient comfort but may not directly address the core issue of delirium.

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