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 planning care for a client who is receiving hemodialysis via an AV fistula. Which of the following interventions should the nurse include in the plan of care?

• A. Avoid taking blood pressures on the arm with the AV fistula.
• B. Check the fistula site daily for pallor.
• C. Place a warm compress over the fistula site every 4 hours.
• D. Keep the client's arm elevated on two pillows.

Correct answer: A

Rationale: The correct intervention is to avoid taking blood pressures on the arm with the AV fistula. This is crucial to prevent complications such as damage to the fistula. Checking the fistula site for pallor is not as important as avoiding blood pressures on the affected arm. Placing warm compresses over the fistula site is not recommended as it can increase the risk of infection. Keeping the client's arm elevated on two pillows is not necessary for the care of an AV fistula.

3. A client with type 2 diabetes mellitus is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?

• A. You should not gain more than 10 lbs
• B. Your weight gain should be the same as for someone without diabetes
• C. Avoid gaining more than 15 lbs
• D. You should gain more weight because of your condition

Correct answer: B

Rationale: The correct answer is B. Clients with type 2 diabetes should aim for the same pregnancy weight gain as those without diabetes. Option A is too restrictive and may not be appropriate for a healthy pregnancy. Option C also imposes a specific limit without considering individual needs. Option D is incorrect as excessive weight gain can lead to complications in pregnancy, especially for individuals with diabetes.

4. A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

• A. I will take this medication before meals
• B. I will mix this medication with water
• C. I will take this medication once a week
• D. I will rinse my mouth after taking this medication

Correct answer: D

Rationale: The correct answer is D because rinsing the mouth is essential to prevent staining and irritation caused by ferrous sulfate elixir. Choices A, B, and C are incorrect. Taking ferrous sulfate elixir before meals (Choice A) is not necessary. Mixing it with water (Choice B) is not recommended as it may alter the medication's effectiveness. Taking the medication once a week (Choice C) is incorrect as ferrous sulfate is usually prescribed daily or as directed by a healthcare provider.

5. What is the first step in assessing a patient with suspected stroke?

• A. Check for facial droop
• B. Assess speech clarity
• C. Perform a neurological assessment
• D. Call for emergency assistance

Correct answer: D

Rationale: The correct answer is to call for emergency assistance (Option D) when assessing a patient with suspected stroke. Time is crucial in stroke management, and activating emergency services promptly can ensure timely access to specialized care such as stroke units and treatments like thrombolytic therapy. Checking for facial droop (Option A), assessing speech clarity (Option B), and performing a neurological assessment (Option C) are important steps in evaluating a stroke but should follow the immediate action of calling for emergency assistance. These initial assessments can help confirm the suspicion of a stroke and provide valuable information to healthcare providers when they arrive. However, the priority is to ensure the patient receives appropriate care without delay by activating emergency services.

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