Nursing Elites

1. What are early indicators of dehydration?

• A. Dry mouth
• B. Increased thirst
• C. Decreased urine output
• D. Dizziness

Correct answer: A

Rationale: The correct answer is A, dry mouth, and B, increased thirst are early indicators of dehydration. Dry mouth occurs when the body is dehydrated, and increased thirst is the body's way of trying to increase fluid intake to combat dehydration. Choices C and D, decreased urine output and dizziness, can be signs of severe dehydration but are not typically considered early indicators.

2. When assessing a client with signs of delirium, which factor should be the nurse's priority in determining the cause?

• A. Medication history
• B. Fluid and electrolyte imbalances
• C. Psychosocial stressors
• D. Environmental factors

Correct answer: B

Rationale: When a nurse assesses a client with signs of delirium, the priority in determining the cause should be focusing on fluid and electrolyte imbalances. Delirium can often be linked to imbalances in these essential elements, making it crucial to address them promptly. While medication history, psychosocial stressors, and environmental factors can also contribute to delirium, they should be assessed after addressing fluid and electrolyte imbalances due to their immediate impact on cognitive function.

3. A client with a chest tube is post-op. What is the priority nursing action?

• A. Clamp the chest tube every 2 hours
• B. Check for air leaks and proper functioning of the chest tube
• C. Encourage deep breathing and coughing every 2 hours
• D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The correct answer is to check for air leaks and ensure the proper functioning of the chest tube. This action is crucial post-op to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube every 2 hours (Choice A) is incorrect as it can lead to a buildup of pressure within the chest, risking complications. Encouraging deep breathing and coughing every 2 hours (Choice C) is important for respiratory hygiene but not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing to clear secretions (Choice D) is not the priority when assessing a chest tube post-op; ensuring the chest tube's integrity and function take precedence.

4. A nurse is reviewing the medical record of a client who is taking enalapril for hypertension. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 150/80 mm Hg
• B. Swelling in the legs
• C. Persistent cough
• D. Heart rate of 72 beats per minute

Correct answer: C

Rationale: The correct answer is C: Persistent cough. Enalapril is known to cause a persistent dry cough as a side effect. This adverse reaction is due to the accumulation of bradykinin in the lungs, leading to irritation and cough. The nurse should report this symptom to the provider for further evaluation and possible medication adjustment. Choices A, B, and D are not directly associated with enalapril use. While a blood pressure of 150/80 mm Hg is elevated and should be monitored, it is not a direct side effect of enalapril. Swelling in the legs and a heart rate of 72 beats per minute are also not typically related to enalapril use and should be assessed but are not the priority findings to report in this scenario.

5. What is the healthcare provider's role in providing patient education about hypertension management?

• A. Encourage lifestyle modifications and medication adherence
• B. Advise patients to avoid physical activity
• C. Recommend a low-sodium diet
• D. Increase potassium in the diet

Correct answer: A

Rationale: The correct answer is A: Encourage lifestyle modifications and medication adherence. Patient education in hypertension management should focus on encouraging lifestyle changes like a healthy diet, exercise, stress management, and adherence to prescribed medications. Choices B, C, and D are incorrect because advising patients to avoid physical activity, recommending a low-sodium diet, and increasing potassium intake, although related to hypertension management, do not encompass the comprehensive approach needed for effective patient education on this topic.

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