Nursing Elites

1. What are the key nursing interventions for a patient undergoing dialysis?

• A. Monitor fluid balance and administer heparin
• B. Monitor blood pressure and prevent clot formation
• C. Administer medications and monitor blood chemistry
• D. Provide dietary education and encourage protein intake

Correct answer: A

Rationale: The correct answer is A: Monitor fluid balance and administer heparin. For a patient undergoing dialysis, it is crucial to monitor fluid balance to prevent fluid overload or depletion. Administering heparin helps prevent clot formation during the dialysis process. Option B is incorrect as while monitoring blood pressure is essential, preventing clot formation is more directly related to heparin administration. Option C is incorrect because administering medications and monitoring blood chemistry are not the primary interventions for dialysis. Option D is incorrect as while dietary education and protein intake are important for overall health, they are not the key nursing interventions specifically for a patient undergoing dialysis.

2. A nurse is caring for a client following an acute myocardial infarction who is concerned about fatigue. What is the best strategy to promote independence in self-care?

• A. Instruct the client to remain in bed until the fatigue resolves
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Assign assistive personnel to perform all self-care tasks for the client
• D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote independence while managing fatigue. This approach allows the client to regain confidence in their abilities and fosters independence. Option A is incorrect as prolonged bed rest can lead to deconditioning and worsen fatigue. Option C is not promoting independence as it involves delegating all self-care tasks to others. Option D involves family assistance, which may be helpful but does not directly promote the client's independence in self-care.

3. When providing discharge teaching to a client with diabetes, what is the most important instruction?

• A. Check blood sugar levels once daily
• B. Administer insulin as prescribed before meals
• C. Take medication only when feeling unwell
• D. Eat carbohydrate-rich meals to stabilize blood sugar

Correct answer: B

Rationale: Administering insulin as prescribed before meals is crucial for managing diabetes. This instruction is vital as it helps the client maintain blood sugar levels within the target range. Checking blood sugar levels once daily is important but not as critical as ensuring the timely administration of insulin. Taking medication only when feeling unwell is dangerous as it may lead to uncontrolled blood sugar levels. Eating carbohydrate-rich meals may actually destabilize blood sugar levels rather than stabilizing them, making it an incorrect choice.

4. A client who is to undergo surgery for a hip fracture is being taught by a nurse about postoperative pain management. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will ask for pain medication only if the pain becomes unbearable.
• B. I will ask the nurse to increase my medication if the pain doesn't subside.
• C. I will wait until the pain is severe before taking my medication.
• D. I will take my medication at regular intervals to stay ahead of the pain.

Correct answer: D

Rationale: The correct answer is D because taking pain medication at regular intervals helps maintain consistent pain control after surgery. Option A is incorrect because waiting for the pain to become unbearable can lead to inadequate pain management. Option B is incorrect as it suggests increasing medication without a schedule. Option C is incorrect because waiting for the pain to be severe before taking medication is not proactive pain management.

5. What are the early signs and symptoms of sepsis?

• A. Increased heart rate and fever
• B. Low blood pressure and confusion
• C. Rapid breathing and sweating
• D. Abdominal pain and cyanosis

Correct answer: A

Rationale: The correct answer is A: Increased heart rate and fever. In sepsis, an increased heart rate and fever are common early signs of systemic infection. While choices B, C, and D can be present in later stages of sepsis, they are not typically the initial signs. Low blood pressure and confusion may occur in severe sepsis or septic shock. Rapid breathing and sweating can be seen as sepsis progresses. Abdominal pain and cyanosis may develop as the condition advances but are not usually the earliest signs.

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