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. A client with dementia is at risk of falling. What is the best intervention to prevent injury?

• A. Place the client in a room close to the nurses' station
• B. Use a bed exit alarm
• C. Encourage family members to stay with the client at all times
• D. Raise all four side rails

Correct answer: B

Rationale: Using a bed exit alarm is the best intervention to prevent injury in a client with dementia at risk of falling. This device alerts staff when the client attempts to leave the bed, allowing for timely assistance and reducing the risk of falls. Placing the client in a room close to the nurses' station may help with supervision but does not provide immediate alerts like a bed exit alarm. Encouraging family members to stay with the client at all times may not be feasible, and raising all four side rails can lead to restraint issues and is not recommended unless necessary for the client's safety.

3. How should a healthcare professional assess a patient with chest pain?

• A. Assess the severity of pain and monitor ECG
• B. Administer nitroglycerin and provide oxygen
• C. Administer aspirin and provide pain relief
• D. Monitor for nausea and administer IV fluids

Correct answer: A

Rationale: When assessing a patient with chest pain, the initial step is to assess the severity of pain and monitor the electrocardiogram (ECG) to look for signs of cardiac issues. Administering nitroglycerin and oxygen (Choice B) is a treatment option for suspected cardiac chest pain but should not precede a thorough assessment. Administering aspirin and providing pain relief (Choice C) may be indicated later, but the priority is to assess the situation first. Monitoring for nausea and administering IV fluids (Choice D) is not the initial assessment for chest pain unless there are specific indications present.

4. Which dietary advice is most appropriate for a client with chronic kidney disease?

• A. Increase intake of fruits and vegetables
• B. Limit intake of potassium-rich foods
• C. Increase intake of dairy products
• D. Reduce intake of protein-rich foods

Correct answer: B

Rationale: The most appropriate dietary advice for a client with chronic kidney disease is to limit intake of potassium-rich foods. In chronic kidney disease, the kidneys have difficulty filtering potassium from the blood, leading to high levels that can be harmful. Therefore, reducing potassium intake is crucial to prevent complications. Choices A, C, and D are not the best options for individuals with chronic kidney disease. Increasing intake of fruits and vegetables (choice A) may actually increase potassium consumption. Increasing intake of dairy products (choice C) can lead to higher phosphorus and potassium levels. Reducing protein-rich foods (choice D) is not the primary focus in the early stages of chronic kidney disease, as protein is necessary for overall health unless kidney function declines significantly.

5. A client with a tracheostomy is exhibiting signs of respiratory distress. What is the nurse's immediate priority?

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

Correct answer: B

Rationale: When a client with a tracheostomy is experiencing respiratory distress, the immediate priority for the nurse is to suction the tracheostomy. This action helps clear the airway of secretions and ensures that the client can breathe effectively. Increasing the oxygen flow rate may be necessary but addressing the airway obstruction is more critical. Notifying the physician immediately is important but may cause a delay in addressing the immediate need for airway clearance. Administering a bronchodilator may help with bronchospasm but should not take precedence over ensuring a clear airway in a client with respiratory distress.

Similar Questions