Nursing Elites

1. What is the most important intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Monitor airway patency
• C. Provide bronchodilators
• D. Call for assistance

Correct answer: A

Rationale: Administering oxygen is crucial in managing a patient experiencing respiratory distress. Oxygen therapy helps to improve oxygen levels in the blood, supporting vital organ functions. While monitoring airway patency is important, administering oxygen takes precedence in ensuring the patient receives an adequate oxygen supply. Providing bronchodilators may be beneficial in certain respiratory conditions, but the immediate priority in distress is to address oxygenation. Calling for assistance is essential, but the immediate intervention to support the patient's respiratory function is administering oxygen.

2. A nurse is teaching a client who is taking warfarin about food and medication interactions. Which of the following foods should the nurse instruct the client to avoid?

• A. Tomatoes
• B. Apples
• C. Broccoli
• D. Green leafy vegetables

Correct answer: D

Rationale: Correct Answer: Green leafy vegetables - Green leafy vegetables are high in vitamin K, which can interfere with the effectiveness of warfarin. Tomatoes, apples, and broccoli are not contraindicated with warfarin therapy. While they are healthy choices, they do not have a significant impact on warfarin's effectiveness.

3. A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?

• A. The client's urine test is positive for glucose and acetone
• B. The client has 1+ pedal edema in both feet at the end of the day
• C. The client complains of an increase in vaginal discharge
• D. The client says she feels pressure against her diaphragm when the baby moves

Correct answer: A

Rationale: The correct answer is A. Positive urine glucose and acetone could indicate gestational diabetes or preeclampsia, both of which are complications. Choice B, pedal edema, is common in pregnancy but may also be a sign of preeclampsia if severe. Choice C, an increase in vaginal discharge, is a normal finding in pregnancy due to hormonal changes. Choice D, pressure against the diaphragm when the baby moves, is a normal sensation due to the growing uterus displacing abdominal contents.

4. A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer oxytocin
• B. Perform fundal massage
• C. Administer IV fluids
• D. Call the provider

Correct answer: B

Rationale: Performing fundal massage is the priority action in this scenario. Fundal massage helps contract the uterus, which is essential in reducing excessive lochia postpartum. Administering oxytocin may be indicated later, but fundal massage should be the initial intervention to address the issue. Administering IV fluids may not directly address the cause of excessive lochia, and calling the provider should come after implementing immediate nursing interventions.

5. What are the signs and symptoms of hyperkalemia and how should it be managed?

• A. Muscle weakness and cardiac arrhythmias; administer calcium gluconate
• B. Confusion and bradycardia; administer insulin and glucose
• C. Fatigue and irregular heart rate; administer diuretics
• D. Nausea and vomiting; administer sodium bicarbonate

Correct answer: A

Rationale: The signs and symptoms of hyperkalemia include muscle weakness and cardiac arrhythmias, making choice A correct. Hyperkalemia can lead to dangerous cardiac effects, and calcium gluconate is used to stabilize the heart by antagonizing the effects of potassium. Choices B, C, and D describe symptoms and interventions that are not typically associated with hyperkalemia. Confusion and bradycardia are not common in hyperkalemia, and insulin and glucose are used in hyperkalemia only under specific circumstances. Fatigue and irregular heart rate are vague symptoms, and diuretics are not the primary treatment for hyperkalemia. Nausea and vomiting are nonspecific symptoms and sodium bicarbonate is not indicated for the management of hyperkalemia.

Similar Questions