Nursing Elites

1. What is the most important intervention for a client with delirium?

• A. Administer sedative medication
• B. Identify any reversible causes of delirium
• C. Provide a low-stimulation environment
• D. Increase environmental stimulation

Correct answer: B

Rationale: The correct answer is to identify any reversible causes of delirium. Delirium can be caused by various factors such as infections, medications, or metabolic imbalances. Addressing these underlying causes can help resolve delirium. Administering sedative medication (Choice A) can worsen delirium by further altering mental status. Providing a low-stimulation environment (Choice C) is helpful to manage delirium symptoms, but it is not the most important intervention. Increasing environmental stimulation (Choice D) is contraindicated in delirium as it can exacerbate confusion and agitation.

2. A client with asthma is being taught how to use a peak flow meter by a nurse. Which of the following instructions should the nurse include?

• A. Perform the test in the morning after taking medications
• B. Blow into the meter as slowly as possible
• C. Perform the test when feeling short of breath
• D. Use the peak flow meter after using your rescue inhaler

Correct answer: D

Rationale: The correct instruction is to use the peak flow meter after using the rescue inhaler. This ensures accurate monitoring of asthma control during symptoms. Choice A is incorrect because peak flow measurements should be done before taking medications. Choice B is incorrect as the client should blow into the meter quickly and forcefully to get an accurate reading. Choice C is also incorrect as peak flow should be measured regularly, not just when feeling short of breath.

3. What are the signs of hypoglycemia, and how should they be managed?

• A. Sweating, trembling; administer glucose
• B. Headache, confusion; administer insulin
• C. Dizziness, fatigue; administer glucose
• D. Increased heart rate; provide a high-sugar snack

Correct answer: A

Rationale: The correct signs of hypoglycemia are sweating and trembling. These should be managed by administering glucose to raise blood sugar levels. Headache, confusion, dizziness, fatigue, or increased heart rate are not typical signs of hypoglycemia. Administering insulin in response to hypoglycemia would further lower blood sugar levels, exacerbating the condition.

4. What are the key signs of hyperkalemia and how should it be treated?

• A. Elevated potassium levels, muscle weakness; administer calcium gluconate
• B. Decreased potassium levels, confusion; administer potassium chloride
• C. Elevated sodium levels, bradycardia; administer sodium bicarbonate
• D. Low sodium levels, muscle cramps; administer sodium chloride

Correct answer: A

Rationale: The correct signs of hyperkalemia include elevated potassium levels and muscle weakness. The treatment involves administering calcium gluconate to help stabilize the heart. Choice B is incorrect as hyperkalemia is characterized by elevated, not decreased, potassium levels. Choice C is incorrect as hyperkalemia does not involve elevated sodium levels, and the treatment is not sodium bicarbonate. Choice D is incorrect as hyperkalemia does not lead to low sodium levels, and sodium chloride is not the treatment for hyperkalemia.

5. What is an appropriate teaching point for a client with left-leg weakness learning to use a cane?

• A. Maintain two points of support on the ground at all times
• B. Use the cane on the weak side of the body
• C. Advance the cane 30 to 45 cm with each step
• D. Advance the cane and the strong leg simultaneously

Correct answer: A

Rationale: The correct teaching point for a client with left-leg weakness learning to use a cane is to maintain two points of support on the ground at all times. This ensures stability and helps prevent falls. Choice B, using the cane on the weak side of the body, may lead to imbalance and decreased support. Choice C, advancing the cane a specific distance with each step, is not as crucial as maintaining two points of support. Choice D, advancing the cane and the strong leg simultaneously, may also compromise stability and support for the weak leg.

Similar Questions