Nursing Elites

1. What are the complications of untreated fluid overload?

• A. Pulmonary edema and congestive heart failure
• B. Hypertension and electrolyte imbalance
• C. Liver failure and electrolyte imbalance
• D. Pulmonary embolism and dehydration

Correct answer: A

Rationale: Corrected Rationale: Untreated fluid overload can lead to complications such as pulmonary edema and congestive heart failure. Pulmonary edema occurs when excess fluid accumulates in the lungs, leading to difficulty breathing and potentially life-threatening respiratory distress. Congestive heart failure can result from the heart's inability to pump effectively due to the excess fluid volume, leading to symptoms such as fatigue, shortness of breath, and fluid retention. Choices B, C, and D are incorrect because hypertension, liver failure, pulmonary embolism, and dehydration are not the primary complications directly associated with untreated fluid overload.

2. A client post-lumbar puncture should be in which position?

• A. High Fowler's position
• B. Prone position
• C. Supine position
• D. Sitting position

Correct answer: C

Rationale: The most appropriate position for a client post-lumbar puncture is the supine position. Placing the client in a supine position helps prevent spinal headaches by allowing the puncture site to seal effectively and reducing the risk of cerebrospinal fluid leakage. High Fowler's position, prone position, and sitting position are not recommended after a lumbar puncture as they may increase the risk of complications like spinal headaches.

3. What are the nursing interventions for a patient with a pressure ulcer?

• A. Clean the wound and apply a hydrocolloid dressing
• B. Provide a high-protein diet and ensure bed rest
• C. Monitor for signs of infection and provide antibiotics
• D. Provide a low-sodium diet and monitor for fluid retention

Correct answer: A

Rationale: The correct nursing intervention for a patient with a pressure ulcer is to clean the wound and apply a hydrocolloid dressing. This promotes healing by creating a moist environment conducive to the wound healing process. Choice B is incorrect because while nutrition is important for wound healing, a high-protein diet alone is not a specific intervention for a pressure ulcer. Choice C is incorrect as antibiotics are only used if there is an infection present. Choice D is also incorrect as a low-sodium diet and monitoring for fluid retention are more related to conditions like heart failure or kidney disease, not specifically pressure ulcer care.

4. A client is receiving IV fluids and has developed phlebitis. What is the next step the nurse should take?

• A. Monitor the site for further swelling
• B. Remove the catheter and place it in another site
• C. Reduce the flow rate of IV fluids
• D. Switch to oral hydration

Correct answer: B

Rationale: The correct next step when a client develops phlebitis while receiving IV fluids is to remove the catheter and place it in another site. Phlebitis is inflammation of a vein, and leaving the catheter in the same site can lead to further complications. Monitoring the site for further swelling, as in choice A, is not enough as the source of inflammation needs to be removed. Choice C, reducing the flow rate, may not address the underlying issue causing phlebitis. Switching to oral hydration, as in choice D, is not necessary for addressing phlebitis related to IV fluid administration.

5. What is the correct procedure for inserting a nasogastric (NG) tube?

• A. Measure the tube and insert with lubrication
• B. Insert with lubrication and no measurement
• C. Insert without lubrication and secure it
• D. Insert with lubrication and check placement

Correct answer: A

Rationale: The correct procedure for inserting a nasogastric (NG) tube involves measuring the tube to ensure the appropriate length for insertion and using lubrication to reduce discomfort and aid in smooth insertion. Choice B is incorrect as measuring the tube is essential for proper placement. Choice C is incorrect as lubrication helps in easing the insertion process. Choice D is incorrect as checking the placement comes after insertion and should not be done simultaneously with the insertion process.

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