Nursing Elites

1. Which of the following is the best position for a patient experiencing dyspnea?

• A. Supine position.
• B. Fowler's position.
• C. Trendelenburg position.
• D. Lateral recumbent position.

Correct answer: B

Rationale: Fowler's position is the best position for a patient experiencing dyspnea. This position involves sitting the patient upright with the head of the bed elevated between 45-60 degrees. Fowler's position helps improve breathing in patients with dyspnea by promoting lung expansion, aiding in better oxygenation, and reducing the work of breathing. The supine position (Choice A) may worsen dyspnea by limiting lung expansion. The Trendelenburg position (Choice C) with the feet elevated and the head down is not recommended for dyspnea as it can increase pressure on the chest and compromise breathing. The lateral recumbent position (Choice D) is not ideal for dyspnea as it does not provide optimal lung expansion and may not alleviate breathing difficulty.

2. A client is receiving intermittent bolus feedings via a nasogastric tube. In which position should the nurse place the client once the feeding is complete?

• A. Supine
• B. Head of bed flat
• C. Left lateral position
• D. Head of bed elevated 30 to 45 degrees

Correct answer: B

Rationale: After intermittent bolus feedings through a nasogastric tube, the correct position for the client is to keep the head of the bed flat. This position helps prevent vomiting and aspiration. Placing the client in a supine position (choice A) can increase the risk of aspiration. The left lateral position (choice C) is not typically used after nasogastric tube feedings. Elevating the head of the bed 30 to 45 degrees (choice D) is suitable for continuous tube feedings to reduce the risk of aspiration, but for intermittent bolus feedings, keeping the head of the bed flat is preferred to prevent regurgitation and aspiration.

3. What is the most important nursing intervention for a patient with increased intracranial pressure (ICP)?

• A. Elevate the head of the bed to 30 degrees.
• B. Administer diuretics to reduce fluid volume.
• C. Administer corticosteroids to reduce inflammation.
• D. Keep the patient in a supine position.

Correct answer: A

Rationale: Elevating the head of the bed to 30 degrees is crucial for a patient with increased intracranial pressure (ICP) because it helps promote venous drainage from the brain, thereby reducing ICP. Keeping the head of the bed elevated helps facilitate cerebral perfusion and can prevent a further increase in ICP. Administering diuretics (Choice B) may be considered in some cases to reduce fluid volume, but it is not the most critical intervention for immediate ICP management. Administering corticosteroids (Choice C) is not typically indicated for managing increased ICP unless there is a specific underlying condition requiring their use. Keeping the patient in a supine position (Choice D) can actually worsen ICP by impeding venous outflow from the brain, making it an incorrect choice for this scenario.

4. The client with chronic renal failure is being taught about the importance of fluid restrictions. Which of the following statements by the client indicates that the teaching has been effective?

• A. I can drink as much fluid as I want, as long as I take my medication.
• B. I will need to limit my fluid intake to prevent fluid overload.
• C. I can drink as much water as I want, as long as I limit other fluids.
• D. I will need to drink only when I am thirsty.

Correct answer: B

Rationale: The correct answer is B: 'I will need to limit my fluid intake to prevent fluid overload.' In chronic renal failure, fluid restrictions are crucial to prevent fluid overload and further damage to the kidneys. Option A is incorrect as unrestricted fluid intake can worsen the condition. Option C is also incorrect as total fluid intake needs to be restricted, not just other fluids. Option D is not ideal because thirst may not accurately reflect the body's fluid needs in chronic renal failure.

5. The nurse assumes care for a patient who is currently receiving a dose of intravenous vancomycin (Vancocin) infusing at 20 mg/min. The nurse notes red blotches on the patient’s face, neck, and chest and assesses a blood pressure of 80/55 mm Hg. Which action will the nurse take?

• A. Request an order for IV epinephrine to treat anaphylactic shock.
• B. Slow the infusion to 10 mg/min and observe the patient closely.
• C. Stop the infusion and obtain an order for a BUN and serum creatinine.
• D. Suspect Stevens-Johnson syndrome and notify the provider immediately.

Correct answer: B

Rationale: When vancomycin is infused too rapidly, “red man” syndrome may occur; the rate should be 10 mg/min to prevent this. This is a toxic reaction, not an allergic one, so epinephrine is not indicated. Stevens-Johnson syndrome is characterized by a rash and fever. Red man syndrome is not related to renal function.

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