Nursing Elites

1. A child is admitted with bacterial meningitis. What assessment finding should the nurse monitor most closely?

• A. Monitor the client’s skin for rash and lesions.
• B. Monitor for signs of increased intracranial pressure.
• C. Monitor the client’s blood pressure closely.
• D. Monitor for changes in heart rate and rhythm.

Correct answer: B

Rationale: Correct Answer: B. Signs of increased intracranial pressure, such as changes in consciousness or pupil reactivity, are critical to monitor in children with bacterial meningitis to prevent complications. Monitoring the client’s skin for rash and lesions (Choice A) is not the priority in bacterial meningitis. While monitoring blood pressure (Choice C) is important, signs of increased intracranial pressure take precedence. Monitoring for changes in heart rate and rhythm (Choice D) is less specific to the condition and may not indicate worsening neurological status.

2. A client with cirrhosis and ascites asks about fluid restriction. What is the nurse’s best response?

• A. Increase the client's fluid intake gradually.
• B. Restrict oral fluids to 1500 ml per day.
• C. Explain the importance of following a low-sodium diet.
• D. Increase dietary protein to reduce fluid retention.

Correct answer: B

Rationale: The correct answer is B: 'Restrict oral fluids to 1500 ml per day.' In clients with cirrhosis and ascites, fluid restriction is essential to prevent fluid overload, which can worsen symptoms of liver failure. Option A is incorrect because increasing fluid intake would exacerbate the issue of fluid overload. Option C, while important, is not the best initial response to the client's question about fluid restriction. Option D is incorrect as increasing dietary protein does not directly address fluid restriction in clients with cirrhosis and ascites.

3. The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?

• A. Cheese sandwich with a glass of 2% milk
• B. Sliced turkey sandwich and canned pineapple
• C. Cheeseburger and baked potato
• D. Mushroom pizza and ice cream

Correct answer: B

Rationale: The correct answer is B. A sliced turkey sandwich and canned pineapple are good choices for a client with congestive heart failure who is learning about sodium restriction. Turkey is generally lower in sodium compared to cheese, and canned fruits like pineapple typically have lower sodium content. Choices A, C, and D are less suitable as they contain higher levels of sodium, such as cheese, cheeseburger, baked potato, mushroom pizza, and ice cream, which are not ideal for a client needing to restrict sodium intake.

4. The nurse is providing care for a client with severe peripheral arterial disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding?

• A. Elevate the legs on pillows
• B. Encourage ambulation and leg exercises
• C. Provide a heating pad for warmth
• D. Offer cold packs when the pain occurs

Correct answer: C

Rationale: Providing warmth can help dilate peripheral vessels and increase blood flow, relieving ischemic pain. In PAD, where there is already compromised blood flow, elevating the legs or applying cold therapy could worsen ischemic pain by further reducing blood flow to the extremities. Encouraging ambulation and leg exercises may be beneficial in other conditions but not suitable for clients with severe PAD experiencing rest ischemia.

5. A client with cirrhosis is at risk for bleeding due to impaired liver function. Which laboratory result is the most important to monitor?

• A. Blood urea nitrogen (BUN)
• B. Prothrombin time (PT)
• C. Aspartate aminotransferase (AST)
• D. Serum albumin

Correct answer: B

Rationale: Prothrombin time (PT) measures the time it takes for blood to clot and is a critical indicator of bleeding risk in clients with liver dysfunction. Impaired liver function reduces clotting factor production, leading to an increased PT, which requires close monitoring. Monitoring BUN (Choice A) is more indicative of kidney function, not clotting ability. Aspartate aminotransferase (AST) (Choice C) and serum albumin (Choice D) are important indicators of liver function, but they do not directly assess the client's bleeding risk.

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