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 preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?

• A. Use sterile gloves
• B. Lubricate the catheter with water
• C. Insert the catheter using clean technique
• D. Open the catheterization kit away from the body

Correct answer: D

Rationale: The correct action for the nurse to take when preparing to insert an indwelling urinary catheter is to open the catheterization kit away from the body. This is crucial to maintain the sterility of the kit and the procedure. Using sterile gloves (Choice A) is important, but it is not specific to this step. Lubricating the catheter with water (Choice B) is incorrect as it should be lubricated with a water-soluble lubricant. Inserting the catheter using clean technique (Choice C) is incorrect as indwelling urinary catheter insertion requires sterile technique to prevent infections.

3. A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days?

• A. The patient eats most of the food served to her
• B. The patient has gained 1 pound since admission
• C. The patient's albumin level is 4.0mg/dL
• D. The patient's hemoglobin is 8.5g/dL

Correct answer: C

Rationale: An improved albumin level is the best indicator of improved nutritional status after TPN. Albumin is a key protein that reflects the body's overall nutritional status and is commonly used to assess nutritional health. Choices A, B, and D are not as reliable indicators of improved nutritional status. Choice A may not accurately reflect nutritional improvement as it could be influenced by factors other than nutrition. Choice B may indicate fluid retention or loss rather than true nutritional improvement. Choice D, hemoglobin level, is more related to anemia and oxygen-carrying capacity of the blood, rather than nutritional status.

4. The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors?

• A. Sleep disturbances
• B. Concomitant depression
• C. Agitation and assaultiveness
• D. Confusion and withdrawal

Correct answer: C

Rationale: The correct answer is C: Agitation and assaultiveness. Risperidone is commonly prescribed for clients with Alzheimer's disease to reduce symptoms of agitation and aggressive behavior. This medication helps in managing challenging behaviors often seen in individuals with Alzheimer's. Choice A, sleep disturbances, is incorrect as risperidone is not primarily indicated for treating sleep issues in Alzheimer's patients. Choice B, concomitant depression, is also incorrect as risperidone is not the first-line treatment for depression in Alzheimer's disease. Choice D, confusion and withdrawal, is incorrect as risperidone does not directly target these symptoms in Alzheimer's patients.

5. A client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take?

• A. Encourage the client to lie down in a quiet room.
• B. Ask the client directly what they are hearing.
• C. Tell the client that the voices are not real.
• D. Provide headphones for the client to listen to music.

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with schizophrenia experiencing auditory hallucinations is to ask the client directly what they are hearing. This approach helps the nurse gain insight into the client's experience, establish effective communication, and provide appropriate support. Encouraging the client to lie down in a quiet room (Choice A) may not address the hallucinations directly. Telling the client that the voices are not real (Choice C) can be invalidating and may lead to further distress. Providing headphones for music (Choice D) may not be effective in addressing the client's hallucinations.

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