Nursing Elites

1. A client is admitted with a diagnosis of fluid volume excess. Which intervention should the nurse include in the client's plan of care?

• A. Encourage increased fluid intake.
• B. Place the client in a high Fowler's position.
• C. Measure the client's intake and output.
• D. Restrict dietary sodium intake.

Correct answer: D

Rationale: Restricting dietary sodium intake (D) is the most critical intervention for a client with fluid volume excess to prevent further fluid retention. Encouraging increased fluid intake (A) would exacerbate the issue by adding more fluid to the body. Placing the client in a high Fowler's position (B) is more relevant for respiratory issues than fluid volume excess. While measuring intake and output (C) is important for assessing fluid balance, restricting sodium intake is the priority as it helps manage fluid levels more effectively by reducing fluid retention.

2. A client is scheduled for a colonoscopy. What instruction should the nurse provide to prepare the client for the procedure?

• A. Drink clear liquids for 24 hours before the procedure
• B. Take a laxative the morning of the procedure
• C. Eat a light meal before the procedure
• D. Avoid drinking fluids for 4 hours before the procedure

Correct answer: A

Rationale: The correct instruction for preparing a client for a colonoscopy is to drink clear liquids for 24 hours before the procedure. This step helps to ensure the bowel is adequately cleared for the colonoscopy, allowing for better visualization and examination of the colon.

3. The daughter of an older woman who became depressed following the death of her husband asks, 'My mother was always well-adjusted until my father died. Will she tend to be sick from now on?' Which response is best for the nurse to provide?

• A. She is almost sure to be less able to adapt than before.
• B. It's highly likely that she will recover and return to her pre-illness state.
• C. If you can interest her in something besides religion, it will help her stay well.
• D. Cultural strains contribute to each woman's tendencies for recurrences of depression.

Correct answer: B

Rationale: The successful resolution of a developmental crisis in the later years involves acceptance and adaptation, and the daughter should be reassured that recovery is likely.

4. A client with cirrhosis and ascites is receiving furosemide 40 mg BID. The pharmacy provides 20 mg tablets. How many tablets should the client receive each day? [Enter numeric value only]

• A. 4 tablets
• B. 3 tablets
• C. 2 tablets
• D. 1 tablet

Correct answer: A

Rationale: To calculate the total daily dose of furosemide needed, 40 mg BID (twice a day) is 80 mg/day. Since each tablet is 20 mg, the client should receive a total of 4 tablets per day (80 mg ÷ 20 mg per tablet = 4 tablets). Therefore, the correct answer is 4 tablets. Choice B (3 tablets) is incorrect because it does not provide the correct total daily dose. Choice C (2 tablets) is incorrect as it would not meet the required dose of 80 mg/day. Choice D (1 tablet) is incorrect as it would be insufficient to achieve the prescribed daily dose.

5. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?

• A. Check the client's carotid pulse.
• B. Encourage the client to get to the toilet.
• C. In a loud voice, call for help.
• D. Gently lower the client to the floor.

Correct answer: D

Rationale: The priority action for the nurse in this situation is to gently lower the client to the floor. This action helps prevent injury to both the client and the nurse. It is important to ensure a safe environment and protect the client from falling, as well as to maintain the nurse's own safety while providing care.

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