Nursing Elites

1. What is the priority intervention for a patient with fluid overload?

• A. Administer diuretics
• B. Administer IV fluids
• C. Provide oral fluids
• D. Provide chest physiotherapy

Correct answer: A

Rationale: The correct answer is to administer diuretics. Diuretics help reduce excess fluid in cases of fluid overload, making it the priority intervention. Administering additional IV fluids (choice B) would exacerbate the problem by adding more fluid. Providing oral fluids (choice C) is not the priority as the excess fluid needs to be removed first. Chest physiotherapy (choice D) is not the primary intervention for fluid overload.

2. A nurse is providing discharge teaching to a client who has a new prescription for digoxin. Which of the following instructions should the nurse include?

• A. Take this medication at bedtime.
• B. Take your pulse before taking this medication.
• C. Avoid eating foods high in potassium.
• D. Take this medication with an antacid.

Correct answer: B

Rationale: The correct instruction for the nurse to include is to advise the client to take their pulse before taking digoxin. This is important to monitor for bradycardia, a potential side effect of the medication. Option A is incorrect because digoxin is usually taken in the morning. Option C is unrelated to digoxin therapy, as high potassium foods are usually restricted in clients taking potassium-sparing diuretics. Option D is incorrect because digoxin should not be taken with antacids as they can affect its absorption.

3. A patient is being cared for by a nurse who has a history of angina and is experiencing chest pain. Which of the following actions should the nurse take first?

• A. Administer oxygen at 2 L/min via nasal cannula.
• B. Administer nitroglycerin sublingually.
• C. Obtain a 12-lead ECG.
• D. Notify the healthcare provider.

Correct answer: C

Rationale: In a patient with a history of angina experiencing chest pain, the priority action for the nurse is to obtain a 12-lead ECG. This helps in assessing for myocardial infarction, a serious condition that requires immediate attention. Administering oxygen, nitroglycerin, or notifying the healthcare provider can be important interventions but obtaining the ECG comes first to determine the presence of myocardial infarction and guide further management.

4. What is the most important assessment for a patient post-op to monitor for complications?

• A. Monitor vital signs
• B. Monitor the surgical site
• C. Check blood glucose levels
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: The correct answer is to monitor vital signs. Post-operative patients need close monitoring of their vital signs to detect early signs of complications such as changes in blood pressure, heart rate, temperature, and respiratory rate. While monitoring the surgical site is also important for signs of infection, assessing vital signs takes precedence as it provides immediate information about the patient's overall condition. Checking blood glucose levels may be essential for specific patients but is not the primary assessment for monitoring post-op complications. Checking for abnormal breath sounds is important but falls secondary to monitoring vital signs as it indicates respiratory issues rather than providing a comprehensive assessment of the patient's condition.

5. A client post-thyroidectomy reports tingling in their lips and fingers. The nurse should identify this finding as an indication of which of the following complications?

• A. Hypokalemia
• B. Hypocalcemia
• C. Hyponatremia
• D. Hyperglycemia

Correct answer: B

Rationale: Tingling in the lips and fingers is a classic sign of hypocalcemia, which can occur as a complication following a thyroidectomy due to inadvertent damage to the parathyroid glands that regulate calcium levels. Hypokalemia (Choice A) presents with muscle weakness and cardiac issues, not tingling. Hyponatremia (Choice C) typically manifests with confusion, seizures, and muscle cramps. Hyperglycemia (Choice D) is associated with increased thirst, frequent urination, and fatigue.

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