Nursing Elites

1. What is the priority nursing intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer bronchodilators
• D. Administer IV fluids

Correct answer: A

Rationale: The correct answer is to administer oxygen. In a patient experiencing respiratory distress, ensuring adequate oxygenation is the priority. Administering oxygen helps improve oxygen levels, which is crucial for the patient's well-being. Repositioning the patient, administering bronchodilators, or giving IV fluids are important interventions in certain situations, but when a patient is in respiratory distress, providing oxygen takes precedence over other actions.

2. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following food choices by the client indicates an understanding of the teaching?

• A. Peanut butter and jelly sandwich
• B. Grilled chicken and rice
• C. Tomato soup with saltine crackers
• D. Baked fish and steamed vegetables

Correct answer: D

Rationale: The correct answer is D, baked fish and steamed vegetables. These food choices are low in potassium and phosphorus, which is important for clients with chronic kidney disease to manage their condition effectively. Grilled chicken and rice (choice B) may be high in phosphorus, tomato soup with saltine crackers (choice C) is high in sodium, and a peanut butter and jelly sandwich (choice A) contains high levels of potassium, all of which are not ideal choices for individuals with chronic kidney disease.

3. A client is 24 hr postoperative following an abdominal aortic aneurysm resection. Which of the following findings is a priority to report?

• A. Serosanguineous drainage on dressing
• B. Abdominal distention
• C. Absent bowel sounds
• D. Urine output of 20 mL/hr

Correct answer: D

Rationale: Urine output less than 30 mL/hr is indicative of decreased kidney function, potentially due to inadequate perfusion or other complications post-aneurysm resection. This finding requires immediate reporting to prevent further complications such as acute kidney injury. Serosanguineous drainage on the dressing, abdominal distention, and absent bowel sounds are also important postoperative assessments but are not as critical as impaired kidney function in this scenario.

4. A client is postoperative following a hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?

• A. Encourage the client to lie flat in bed.
• B. Apply heat to the incision site.
• C. Use an abduction pillow between the client's legs.
• D. Place a trochanter roll under the client's knees.

Correct answer: C

Rationale: Using an abduction pillow between the client's legs is essential in maintaining proper alignment and preventing dislocation of the hip joint following a hip arthroplasty. Encouraging the client to lie flat in bed (Choice A) is not recommended as early mobilization is crucial for preventing complications. Applying heat to the incision site (Choice B) is not typically done immediately postoperatively. Placing a trochanter roll under the client's knees (Choice D) is not as beneficial as using an abduction pillow to maintain proper positioning.

5. A nurse is reviewing the medical record of a client who has major depressive disorder and is taking tranylcypromine. Which of the following foods should the nurse instruct the client to avoid?

• A. Milk
• B. Bananas
• C. Yogurt
• D. Cured meats

Correct answer: D

Rationale: The correct answer is D: Cured meats. Cured meats contain tyramine, which can lead to a hypertensive crisis in clients taking tranylcypromine. Bananas, milk, and yogurt do not contain significant amounts of tyramine and are safe for clients taking this medication. Therefore, the nurse should instruct the client to avoid cured meats to prevent adverse effects.

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