Nursing Elites

1. What is the priority nursing intervention for a patient experiencing an acute asthma attack?

• A. Administer bronchodilators
• B. Monitor oxygen saturation
• C. Provide supplemental oxygen
• D. Start IV fluids

Correct answer: A

Rationale: The correct answer is to administer bronchodilators. In an acute asthma attack, the priority is to open the airways and improve airflow. Bronchodilators like albuterol are crucial in providing immediate relief to the patient. Monitoring oxygen saturation (choice B) is important but administering bronchodilators takes precedence in managing the acute attack. Providing supplemental oxygen (choice C) may be necessary but addressing the airway obstruction with bronchodilators is the priority. Starting IV fluids (choice D) is not the priority in an acute asthma attack unless specifically indicated for other reasons such as dehydration.

2. A nurse is assessing a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

• A. Increased appetite
• B. Dry mucous membranes
• C. Hypotension
• D. Hyperreflexia

Correct answer: C

Rationale: A sodium level of 125 mEq/L indicates hyponatremia, which can lead to hypotension. Hyponatremia is associated with signs such as confusion and weakness, rather than increased appetite, dry mucous membranes, or hyperreflexia. Therefore, the nurse should expect hypotension as a finding in a client with a sodium level of 125 mEq/L.

3. A nurse is providing dietary teaching to a client with irritable bowel syndrome (IBS). Which of the following recommendations should the nurse include?

• A. Consume foods high in bran fiber.
• B. Increase intake of milk products.
• C. Sweeten foods with fructose corn syrup.
• D. Increase intake of foods high in gluten.

Correct answer: A

Rationale: The correct recommendation for a client with irritable bowel syndrome (IBS) is to consume foods high in bran fiber. Bran fiber promotes regularity and helps reduce IBS symptoms by aiding digestion and preventing constipation. Choices B, C, and D are incorrect. Increasing intake of milk products may exacerbate IBS symptoms in some individuals due to lactose intolerance. Sweetening foods with fructose corn syrup can worsen IBS symptoms as it may cause bloating and gas. Increasing intake of foods high in gluten may also be problematic for individuals with IBS as gluten-containing foods can trigger symptoms like abdominal pain and diarrhea.

4. A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse implement?

• A. Use a donut-shaped cushion for sitting
• B. Turn the client every 4 hours
• C. Elevate the head of the bed to 45 degrees
• D. Massage reddened areas to increase circulation

Correct answer: C

Rationale: Elevating the head of the bed reduces pressure on bony prominences, which helps prevent pressure ulcers.

5. A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following interventions should the nurse include in the plan of care?

• A. Apply heat to the incision site.
• B. Keep the client's knee flexed while in bed.
• C. Place a pillow under the client's knee while in bed.
• D. Place a pillow under the client's lower legs.

Correct answer: D

Rationale: Placing a pillow under the client's lower legs is the correct intervention because it helps prevent pressure on the incision site and promotes circulation. Elevating the lower legs also aids in reducing swelling and improving blood flow. Applying heat to the incision site (Choice A) is contraindicated in the early postoperative period as it can increase inflammation and the risk of infection. Keeping the client's knee flexed while in bed (Choice B) may lead to contractures or limited extension of the knee joint. Placing a pillow under the client's knee (Choice C) may cause hyperextension of the knee, which is also not recommended post knee arthroplasty.

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