Nursing Elites

1. What is the best intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Reposition the patient

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation. Oxygen therapy is the initial and priority intervention to ensure an adequate oxygen supply to the body tissues. Administering bronchodilators (Choice B) may be appropriate for specific respiratory conditions like asthma or COPD but is not the first-line intervention in all cases of respiratory distress. Administering IV fluids (Choice C) is not a standard intervention for respiratory distress unless there is an underlying cause like dehydration. Repositioning the patient (Choice D) can aid in optimizing ventilation but is not the primary intervention for respiratory distress.

2. What is the best way to assess for fluid overload in a patient with heart failure?

• A. Check daily weight
• B. Check blood pressure
• C. Monitor heart sounds
• D. Assess for jugular vein distention

Correct answer: A

Rationale: The correct answer is to 'Check daily weight.' Monitoring daily weight is the most accurate method to assess for fluid overload in patients with heart failure. Weight gain can indicate fluid retention, a common issue in heart failure patients. Checking blood pressure (Choice B) can provide information about hemodynamic status but may not be as specific for fluid overload as monitoring weight. Monitoring heart sounds (Choice C) can provide information about cardiac function but may not directly assess fluid overload. Assessing for jugular vein distention (Choice D) can be a sign of increased central venous pressure but may not always correlate with fluid overload as accurately as daily weight checks.

3. A nurse is caring for a client with schizophrenia. Which of the following assessment findings should the nurse expect?

• A. Decreased level of consciousness
• B. Inability to identify common objects
• C. Poor problem-solving ability
• D. Preoccupation with somatic disturbances

Correct answer: B

Rationale: In schizophrenia, clients often display an inability to identify common objects due to cognitive impairment. This is known as associative agnosia, where individuals struggle to recognize familiar objects, faces, or sounds. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head trauma or drug overdose. Poor problem-solving ability may be seen in various mental health disorders but is not specific to schizophrenia. Preoccupation with somatic disturbances is more commonly seen in somatic symptom disorders or somatic delusions, not a typical finding in schizophrenia.

4. When providing dietary teaching for a new prescription of phenelzine, which of the following foods should be avoided?

• A. Broccoli
• B. Yogurt
• C. Cream Cheese
• D. Fruit Juice

Correct answer: A

Rationale: The correct answer is A, Broccoli. Foods high in tyramine, such as broccoli, should be avoided when taking MAOIs like phenelzine to prevent a hypertensive crisis. Yogurt, cream cheese, and fruit juice do not contain significant levels of tyramine and can be safely consumed while on phenelzine.

5. A client with thrombocytopenia is receiving care from a nurse. Which of the following actions should the nurse include?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving the client raw vegetables.

Correct answer: C

Rationale: In a client with thrombocytopenia, the platelet count is low, leading to a risk of bleeding. Providing a stool softener is essential to prevent constipation and straining during bowel movements, which can reduce the risk of bleeding episodes. Encouraging the client to floss daily (Choice A) is a good oral hygiene practice but is not directly related to thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is related to infection control but does not address the specific risk of bleeding in thrombocytopenia. Avoiding serving the client raw vegetables (Choice D) is important in clients with neutropenia to prevent infections, not in thrombocytopenia.

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