Nursing Elites

1. What is the first step in managing a client with delirium?

• A. Administer sedative medication to calm the client
• B. Identify any reversible causes of delirium
• C. Limit environmental stimulation to reduce anxiety
• D. Administer antipsychotic medication to control behavior

Correct answer: B

Rationale: The correct first step in managing a client with delirium is to identify any reversible causes of delirium. This is crucial because addressing the underlying cause can help in resolving delirium more effectively. Administering sedative or antipsychotic medications without addressing the root cause may not be helpful and can even worsen the condition. Limiting environmental stimulation, although important, is not the primary step in managing delirium.

2. A healthcare provider is assessing a client who has received a preoperative dose of morphine. Which of the following findings is the priority to report to the provider?

• A. Client reports nausea.
• B. Urinary output of 20 mL/hr.
• C. Oxygen saturation 90%.
• D. Respiratory rate 14/min.

Correct answer: C

Rationale: An oxygen saturation of 90% is below the expected reference range and could indicate respiratory depression, a serious side effect of morphine. This finding requires immediate attention as it may lead to hypoxia. Nausea (choice A) is a common side effect of morphine but does not pose an immediate threat. A urinary output of 20 mL/hr (choice B) may indicate decreased renal perfusion but is not as critical as respiratory compromise. A respiratory rate of 14/min (choice D) is within the normal range and does not suggest immediate danger.

3. How should a healthcare professional manage a patient with fluid overload?

• A. Restrict fluids and administer diuretics
• B. Increase fluid intake and provide oral diuretics
• C. Administer antibiotics and monitor weight
• D. Monitor weight and provide a low-sodium diet

Correct answer: A

Rationale: Corrected Question: When managing a patient with fluid overload, the appropriate approach involves restricting fluids and administering diuretics. This strategy helps remove excess fluid from the body and prevent complications associated with fluid overload. Choice B suggesting increasing fluid intake is incorrect as it would worsen the condition. Choice C, administering antibiotics, is unrelated to managing fluid overload. Choice D, monitoring weight and providing a low-sodium diet, is helpful but not as effective as fluid restriction and diuretics in managing fluid overload.

4. What are the key differences between systolic and diastolic heart failure?

• A. Systolic: Reduced ejection fraction; Diastolic: Preserved ejection fraction
• B. Systolic: Preserved ejection fraction; Diastolic: Reduced ejection fraction
• C. Systolic: Right-sided heart failure; Diastolic: Left-sided heart failure
• D. Systolic: Pulmonary congestion; Diastolic: Systemic congestion

Correct answer: A

Rationale: The correct answer is A. Systolic heart failure is characterized by reduced ejection fraction, meaning the heart is not pumping effectively. Diastolic heart failure, on the other hand, is characterized by preserved ejection fraction, indicating that the heart has difficulty relaxing and filling properly. Choices B, C, and D are incorrect because they do not accurately describe the key differences between systolic and diastolic heart failure.

5. A client is constipated and asks the nurse for advice. What should the nurse recommend?

• A. Administer a laxative to relieve discomfort
• B. Increase dietary fiber to promote bowel movements
• C. Advise the client to rest until symptoms resolve
• D. Encourage bed rest to allow bowel function to return

Correct answer: B

Rationale: The correct recommendation for constipation is to increase dietary fiber to promote bowel movements. Dietary fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Administering a laxative (Choice A) is not the first-line recommendation and should be used cautiously due to potential side effects. Resting until symptoms resolve (Choice C) and encouraging bed rest (Choice D) are not effective interventions for relieving constipation.

Similar Questions