Nursing Elites

1. What is the priority intervention when managing a client with delirium?

• A. Administer antipsychotic medication to calm the client
• B. Identify any reversible causes of delirium
• C. Provide a low-stimulation environment
• D. Administer sedative medication to control agitation

Correct answer: B

Rationale: The correct answer is to identify any reversible causes of delirium. Delirium is often caused by underlying issues such as infections, medication side effects, or metabolic imbalances. Addressing these root causes can help resolve delirium more effectively. Administering antipsychotic or sedative medications should not be the initial approach as they can worsen delirium in some cases. Providing a low-stimulation environment is beneficial but not the priority when reversible causes need to be addressed first.

2. A nurse is planning to irrigate and dress a clean, granulating wound for a client. Which of the following actions should the nurse take?

• A. Irrigate the wound with normal saline.
• B. Apply a wet-to-dry gauze dressing.
• C. Use a cotton ball to cleanse the wound.
• D. Administer an analgesic after the dressing change.

Correct answer: A

Rationale: The correct answer is to irrigate the wound with normal saline. Normal saline is the preferred solution for wound irrigation as it is isotonic and gentle, promoting healing in granulating wounds. Choice B, applying a wet-to-dry gauze dressing, is not appropriate for clean, granulating wounds as it can cause trauma to the wound bed upon removal. Choice C, using a cotton ball to cleanse the wound, is not ideal as cotton fibers can adhere to the wound and cause contamination. Choice D, administering an analgesic after the dressing change, is important for pain management but is not directly related to irrigating and dressing the wound.

3. How should a healthcare provider manage a patient with dehydration?

• A. Monitor fluid intake
• B. Encourage oral rehydration
• C. Administer IV fluids
• D. All of the above

Correct answer: D

Rationale: Dehydration management involves a comprehensive approach that includes monitoring fluid intake to assess the severity of dehydration, encouraging oral rehydration to replenish fluids orally if the patient can tolerate it, and administering IV fluids in severe cases where oral intake is insufficient. Choosing just one of these options may not address the diverse needs of patients with dehydration. Therefore, selecting 'All of the above' is the most appropriate response as it encompasses the various strategies required for effective dehydration management.

4. How should a healthcare provider educate a patient with hypertension about lifestyle modifications?

• A. Reduce sodium intake
• B. Increase physical activity
• C. Quit smoking
• D. Avoid alcohol

Correct answer: A

Rationale: When educating a patient with hypertension about lifestyle modifications, reducing sodium intake is crucial as excess sodium can contribute to high blood pressure. While increasing physical activity is beneficial for overall health, it is not the primary lifestyle modification specifically targeted at hypertension. Quitting smoking and avoiding alcohol are important for general health but are not the first-line lifestyle modifications recommended for hypertension. Therefore, the correct answer is to reduce sodium intake.

5. Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?

• A. Explain the experience of having delirium
• B. Resume a normal sleep-wake cycle
• C. Regain orientation to time and place
• D. Establish normal bowel and bladder function

Correct answer: C

Rationale: Regaining orientation to time and place is a realistic short-term goal for clients with delirium. It helps the individual become aware of their surroundings and current situation, aiding in reducing confusion and disorientation. Choice A is incorrect because the goal is focused on the client's understanding, not on explaining the experience of delirium. Choice B, resuming a normal sleep-wake cycle, may take longer than 2 to 3 days to achieve and is not directly related to regaining orientation. Choice D, establishing normal bowel and bladder function, is important but may not be a short-term goal specifically related to delirium.

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