Nursing Elites

1. What is the initial action for a healthcare provider when a patient presents with shortness of breath?

• A. Administer oxygen
• B. Reposition the patient
• C. Check for abnormal breath sounds
• D. Check oxygen saturation

Correct answer: A

Rationale: Administering oxygen is the initial action for a healthcare provider when a patient presents with shortness of breath because it helps alleviate the patient's symptoms by improving oxygenation. Providing oxygen takes precedence over other actions such as repositioning the patient, checking for abnormal breath sounds, or assessing oxygen saturation. While these actions are important, ensuring the patient has an adequate oxygen supply is crucial in the initial management of shortness of breath.

2. A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

• A. Apply skin preparation to wound edges.
• B. Don sterile gloves.
• C. Normal saline
• D. Determine pain level.

Correct answer: D

Rationale: The correct answer is to determine the pain level first. Assessing the client's pain is crucial before any procedure to ensure their comfort and safety. Applying skin preparation to wound edges (Choice A) may come later in the process after ensuring the client's comfort. Donning sterile gloves (Choice B) is important before directly handling the wound but can follow pain assessment. Normal saline (Choice C) might be used during wound cleansing but is not the initial step in this situation.

3. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which manifestation should the nurse expect?

• A. Loose stools.
• B. Jitteriness.
• C. Hypertonia.
• D. Abdominal distention.

Correct answer: B

Rationale: Jitteriness is a common symptom of neonatal hypoglycemia. When a newborn has a low blood glucose level, they may exhibit signs of central nervous system dysfunction, such as jitteriness. Loose stools (Choice A) are not typically associated with neonatal hypoglycemia. Hypertonia (Choice C) refers to increased muscle tone, which is not a common manifestation of hypoglycemia in newborns. Abdominal distention (Choice D) is more often associated with gastrointestinal issues rather than hypoglycemia.

4. When a client with schizophrenia who experiences auditory hallucinations says, 'It's hard not to listen to the voices,' which question should the nurse ask?

• A. Do you understand that the voices are not real?
• B. Why do you think the voices are talking to you?
• C. Have you tried going to a private place when this occurs?
• D. What helps you ignore what you are hearing?

Correct answer: D

Rationale: The correct question for the nurse to ask the client who experiences auditory hallucinations and finds it hard not to listen to the voices is, 'What helps you ignore what you are hearing?' This question focuses on promoting coping strategies and therapeutic communication, encouraging the client to share what techniques or interventions have been effective for managing the auditory hallucinations. Choice A is incorrect because it assumes the client does not understand that the voices are not real, which may not be the case. Choice B delves into the reasons behind the voices, which may not be immediately helpful in managing the current situation. Choice C suggests a physical solution of going to a private place, which may not address the underlying issue of coping with the voices.

5. How should a healthcare provider monitor a patient with fluid overload?

• A. Monitor daily weight
• B. Check for edema
• C. Monitor input and output
• D. Monitor blood pressure

Correct answer: A

Rationale: Monitoring daily weight is crucial in assessing fluid retention accurately in a patient with fluid overload. Changes in weight can indicate fluid accumulation or loss, providing valuable information for healthcare providers. Checking for edema (choice B) is important but may not always accurately reflect total body fluid status. Monitoring input and output (choice C) and blood pressure (choice D) are also essential aspects of patient assessment, but they may not directly reflect the extent of fluid overload as effectively as monitoring daily weight.

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