Nursing Elites

1. What are the key signs of infection after surgery?

• A. Redness
• B. Swelling
• C. Fever
• D. All of the above

Correct answer: D

Rationale: After surgery, key signs of infection include redness, swelling, and fever. Redness and swelling can indicate inflammation at the surgical site, while fever is a systemic response to infection. Choosing 'All of the above' (Option D) is the correct answer because all three signs are commonly associated with post-surgical infections. Options A, B, and C are incorrect as each of them individually can be a sign of infection, but considering all three together provides a more comprehensive assessment for post-operative infection.

2. A client at 30 weeks of gestation reports constipation. Which of the following recommendations should the nurse make?

• A. Drink 1 liter of water per day.
• B. Take a laxative every morning.
• C. Increase your intake of refined grains.
• D. Walk for at least 30 minutes every day.

Correct answer: D

Rationale: The correct recommendation is to walk for at least 30 minutes every day. Walking stimulates intestinal motility, which can help relieve constipation during pregnancy. Option A is important for overall hydration but may not directly address constipation. Option B is not recommended without healthcare provider approval as some laxatives are contraindicated in pregnancy. Option C, increasing intake of refined grains, may exacerbate constipation due to lower fiber content.

3. A client with a tracheostomy is exhibiting signs of respiratory distress. What should the nurse do first?

• A. Notify the healthcare provider
• B. Suction the tracheostomy
• C. Administer a bronchodilator
• D. Increase the oxygen flow rate

Correct answer: B

Rationale: When a client with a tracheostomy is experiencing respiratory distress, the priority action is to suction the tracheostomy to clear the airway and improve breathing. This helps remove secretions or blockages that may be causing the distress. Notifying the healthcare provider (Choice A) can be done after ensuring immediate airway clearance. Administering a bronchodilator (Choice C) would not address the primary issue of airway clearance in a tracheostomy patient. Increasing the oxygen flow rate (Choice D) may be necessary but should come after ensuring the airway is clear.

4. A client who is to undergo an exercise stress test is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should eat a large meal 2 hours before the test
• B. I should avoid drinking water before the test
• C. I should stop taking my blood pressure medication
• D. I should report any chest pain during the test

Correct answer: D

Rationale: The correct answer is D: 'I should report any chest pain during the test.' This statement indicates an understanding of the teaching because reporting chest pain during an exercise stress test is crucial as it may signify cardiac distress. Choices A, B, and C are incorrect. Eating a large meal 2 hours before the test is not recommended as it may affect the results. Avoiding drinking water before the test is also not advisable as staying hydrated is important. Stopping blood pressure medication without medical advice can be dangerous, especially before a stress test.

5. Which of the following interventions should the nurse implement for a client with hyperkalemia?

• A. Administer calcium gluconate
• B. Increase fluid intake to promote potassium excretion
• C. Administer a diuretic
• D. Administer sodium bicarbonate

Correct answer: A

Rationale: The correct intervention for a client with hyperkalemia is to administer calcium gluconate. Calcium gluconate helps counteract the effects of hyperkalemia by stabilizing the cardiac cell membrane. Increasing fluid intake (Choice B) may not effectively lower potassium levels. Administering a diuretic (Choice C) or sodium bicarbonate (Choice D) is not the primary treatment for hyperkalemia and may not address the immediate need to lower potassium levels.

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