Nursing Elites

1. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is:

• A. difference in the intake and output
• B. changes in the mucous membranes
• C. skin turgor
• D. weekly weight

Correct answer: D

Rationale: In a client with altered renal function, monitoring fluid balance is crucial. Weekly weight is the most accurate indicator of fluid balance during the visits as it reflects cumulative changes in the body's fluid status. Changes in intake and output (Choice A) can provide valuable information, but weekly weight is a more direct measure of overall fluid retention or loss. Changes in mucous membranes (Choice B) and skin turgor (Choice C) can be influenced by factors other than fluid balance, making them less reliable indicators in this context.

2. A client is diagnosed with methicillin-resistant Staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?

• A. Reverse
• B. Airborne
• C. Standard precautions
• D. Contact

Correct answer: D

Rationale: The correct answer is 'D: Contact.' Contact precautions are necessary for clients with MRSA pneumonia to prevent the spread of the resistant bacteria. MRSA is primarily spread by direct contact, so using contact precautions, such as wearing gloves and gowns, is essential. Choice A, 'Reverse,' is not a type of isolation precaution. Choice B, 'Airborne,' is not the appropriate isolation for MRSA pneumonia, as MRSA is not transmitted through the airborne route. Choice C, 'Standard precautions,' are important for all clients, but for MRSA pneumonia specifically, contact precautions are more targeted and necessary.

3. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?

• A. The tube will drain fluid from your chest.
• B. The tube will remove excess air from your chest.
• C. The tube controls the amount of air that enters your chest.
• D. The tube will seal the hole in your lung.

Correct answer: B

Rationale: The correct answer is B: 'The tube will remove excess air from your chest.' In a spontaneous pneumothorax, air accumulates in the pleural space, causing lung collapse. The chest tube is inserted to remove this excess air, allowing the lung to re-expand. Choices A, C, and D are incorrect because the primary purpose of a chest tube in pneumothorax is to evacuate air, not fluid, control air entry, or seal a lung hole.

4. A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements by the client indicates an understanding of the dietary teaching?

• A. Eating yogurt can help decrease gas odor that I have.
• B. I should eliminate pasta from my diet so that I don't have as many loose stools.
• C. My largest meal of the day should be in the evening.
• D. Carbonated beverages can help control odor.

Correct answer: A

Rationale: The correct answer is A. Yogurt contains probiotics which can help reduce gas and odor in colostomy patients. Choice B is incorrect because pasta is a low-fiber food that can help thicken stools, which may be beneficial for colostomy patients. Choice C is incorrect because it is generally recommended for colostomy patients to have their largest meal earlier in the day to allow for better digestion. Choice D is incorrect because carbonated beverages can actually increase gas production and worsen odor in colostomy patients.

5. A client with hypertension taking a potassium-wasting diuretic is being educated about nutrition by a nurse. Which of the following dietary instructions should the nurse include in the teaching?

• A. Increase consumption of tuna and salmon.
• B. Limit intake of dried fruits.
• C. Avoid cow's milk.
• D. Consume organs and bananas

Correct answer: D

Rationale: The correct answer is D: 'Consume organs and bananas.' When a client is taking a potassium-wasting diuretic, they are at risk of potassium loss. Consuming foods high in potassium, such as organs and bananas, can help counteract this loss. Choice A is incorrect because tuna and salmon are not particularly high in potassium. Choice B is incorrect because dried fruits are good sources of potassium. Choice C is incorrect as cow's milk is also a good source of potassium, which could be beneficial for a client taking a potassium-wasting diuretic.

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