Nursing Elites

1. What is the first priority for a patient in respiratory distress?

• A. Administer oxygen
• B. Assess airway patency
• C. Monitor oxygen saturation
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to administer oxygen. In a patient experiencing respiratory distress, the primary concern is ensuring an adequate oxygen supply to the body. By administering oxygen, you can help improve oxygenation, which is crucial for the patient's overall well-being. Assessing airway patency is important but administering oxygen takes precedence as it directly addresses the oxygenation concern. Monitoring oxygen saturation is also essential, but the immediate action should be to provide oxygen. Calling for assistance can be important but is not the first priority when dealing with a patient in respiratory distress.

2. A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for the client?

• A. White flour tortillas.
• B. Potato pancakes.
• C. Wheat crackers.
• D. Canned barley soup.

Correct answer: B

Rationale: The correct answer is B, potato pancakes. Individuals with celiac disease must avoid gluten-containing foods. Potato pancakes are gluten-free, making them a suitable choice for someone with celiac disease. Choice A, white flour tortillas, contains gluten from wheat flour, making it unsuitable for a client with celiac disease. Choice C, wheat crackers, also contain gluten and should be avoided. Choice D, canned barley soup, contains barley which is a gluten-containing grain and is not appropriate for someone with celiac disease.

3. A client is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?

• A. The client is experiencing an adverse reaction to rifampin.
• B. The client's seizure disorder is no longer under control.
• C. The client is showing evidence of phenytoin toxicity.
• D. The client is having adverse effects due to combination antimicrobial therapy.

Correct answer: C

Rationale: Ataxia and incoordination are signs of phenytoin toxicity rather than adverse reactions to rifampin or isoniazid. These symptoms indicate that the client is experiencing an adverse effect of phenytoin, requiring a dose adjustment. Choice A is incorrect because rifampin is not typically associated with ataxia and incoordination. Choice B is incorrect as the development of ataxia and incoordination does not necessarily mean the seizure disorder is no longer under control. Choice D is incorrect as the symptoms are more indicative of phenytoin toxicity rather than adverse effects of combination antimicrobial therapy.

4. How should a healthcare provider manage a patient with sepsis?

• A. Administer IV antibiotics
• B. Monitor vital signs
• C. Administer fluids
• D. All of the above

Correct answer: D

Rationale: Managing a patient with sepsis requires a multi-faceted approach. Administering IV antibiotics is crucial to combat the underlying infection. Monitoring vital signs such as heart rate, blood pressure, respiratory rate, and temperature helps assess the patient's response to treatment and identify any deterioration. Administering fluids is essential to maintain adequate blood pressure and organ perfusion. Therefore, all the options are integral components of sepsis management, making 'All of the above' the correct answer. Choices A, B, and C are all essential in the comprehensive care of a patient with sepsis. Omitting any of these aspects can lead to suboptimal outcomes, as each plays a critical role in addressing different aspects of sepsis management.

5. What are the nursing interventions for a patient with a pressure ulcer?

• A. Clean the wound and apply a hydrocolloid dressing
• B. Provide a high-protein diet and ensure bed rest
• C. Monitor for signs of infection and provide antibiotics
• D. Provide a low-sodium diet and monitor for fluid retention

Correct answer: A

Rationale: The correct nursing intervention for a patient with a pressure ulcer is to clean the wound and apply a hydrocolloid dressing. This promotes healing by creating a moist environment conducive to the wound healing process. Choice B is incorrect because while nutrition is important for wound healing, a high-protein diet alone is not a specific intervention for a pressure ulcer. Choice C is incorrect as antibiotics are only used if there is an infection present. Choice D is also incorrect as a low-sodium diet and monitoring for fluid retention are more related to conditions like heart failure or kidney disease, not specifically pressure ulcer care.

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