Nursing Elites

1. What is the most appropriate action when a patient is experiencing severe dehydration?

• A. Administer IV fluids
• B. Encourage oral fluids
• C. Monitor electrolytes
• D. Perform a neurological exam

Correct answer: A

Rationale: The most appropriate action when a patient is experiencing severe dehydration is to administer IV fluids. This intervention is crucial in rapidly correcting dehydration and restoring fluid balance. Encouraging oral fluids may not be sufficient in cases of severe dehydration where intravenous rehydration is needed. Monitoring electrolytes is important but administering fluids takes precedence in severe dehydration. Performing a neurological exam is not the primary intervention for severe dehydration.

2. A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?

• A. Abdominal cramps
• B. Irritability
• C. Increased thirst
• D. Blurred vision

Correct answer: B

Rationale: Irritability is a common early manifestation of hypoglycemia. When blood glucose levels drop, the brain perceives this as a stressor, leading to irritability. Abdominal cramps (choice A) are not typically associated with hypoglycemia but can occur with other gastrointestinal issues. Increased thirst (choice C) is more indicative of hyperglycemia rather than hypoglycemia. Blurred vision (choice D) is a symptom more commonly associated with hyperglycemia rather than hypoglycemia.

3. A nurse in an emergency department is caring for a client who reports cocaine use 1 hour ago. Which of the following findings should the nurse expect?

• A. Hypotension.
• B. Memory loss.
• C. Slurred speech.
• D. Elevated temperature.

Correct answer: D

Rationale: The correct answer is D: Elevated temperature. Cocaine is a stimulant drug that can lead to increased body temperature. Hypotension (Choice A) is less likely as cocaine tends to elevate blood pressure. Memory loss (Choice B) and slurred speech (Choice C) are more commonly associated with depressant drugs rather than stimulant drugs like cocaine.

4. 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.

5. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

• A. Request a renewal of the prescription every 8 hours.
• B. Check the client's peripheral pulse every 30 minutes.
• C. Obtain a prescription for restraints within 4 hours.
• D. Document the client's condition every 15 minutes.

Correct answer: D

Rationale: In the scenario presented, the correct action for the nurse to take when caring for a client with a verbal prescription for restraints due to acute mania is to document the client's condition every 15 minutes. Documenting at regular intervals is essential to monitor the client's well-being, assess the effects of the restraints, and ensure the client's safety. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary as the focus should be on monitoring the client's condition. Checking the client's peripheral pulse every 30 minutes (Choice B) is important but not as crucial as documenting the overall condition. Obtaining a prescription for restraints within 4 hours (Choice C) is not the immediate action needed when a verbal prescription is already obtained.

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