Nursing Elites

1. A client with acute pancreatitis is receiving nothing by mouth (NPO) status. What is the nurse's priority intervention?

• A. Administer antiemetic medication as prescribed.
• B. Monitor the client's intake and output.
• C. Provide mouth care to keep the client comfortable.
• D. Elevate the client's head of the bed.

Correct answer: B

Rationale: The correct answer is B: Monitor the client's intake and output. When a client with acute pancreatitis is on NPO status, the nurse's priority intervention is to monitor the client's intake and output. This is crucial to assess for signs of dehydration, electrolyte imbalances, and to ensure the client is responding appropriately to treatment. Administering antiemetic medication (choice A) may be necessary for managing nausea and vomiting but is not the priority over monitoring intake and output. Providing mouth care (choice C) and elevating the client's head of the bed (choice D) are important aspects of care but do not take precedence over monitoring intake and output to prevent complications in clients with NPO status due to acute pancreatitis.

2. A client receiving radiation therapy for breast cancer reports dry, peeling skin at the treatment site. What action should the nurse recommend?

• A. Apply lotion to the treatment area.
• B. Use mild soap and water to cleanse the area.
• C. Cover the area with a sterile dressing.
• D. Allow the skin to air dry after washing.

Correct answer: B

Rationale: The correct recommendation for a client with dry, peeling skin at a radiation therapy treatment site is to use mild soap and water to cleanse the area. This approach helps in preventing skin irritation and reduces the risk of infection. Applying lotion (Choice A) may further irritate the skin due to the chemicals present in the lotion. Covering the area with a sterile dressing (Choice C) is not necessary unless there is an open wound that needs protection. Allowing the skin to air dry after washing (Choice D) may lead to further dryness and peeling.

3. A nurse is planning discharge teaching for a client with congestive heart failure (CHF). Which dietary instruction should the nurse provide?

• A. Limit sodium intake to reduce fluid retention
• B. Consume high-protein foods to strengthen the heart
• C. Increase potassium intake to manage blood pressure
• D. Increase fluid intake to promote hydration

Correct answer: A

Rationale: The correct answer is A: Limit sodium intake to reduce fluid retention. Limiting sodium intake is crucial for managing congestive heart failure (CHF) as it helps reduce fluid retention. Excess fluid retention can worsen CHF by increasing the workload on the heart. Choice B is incorrect because while protein is essential for overall health, it is not directly related to managing CHF. Choice C is incorrect because potassium, although important, is not the primary focus in managing CHF. Choice D is incorrect because increasing fluid intake can exacerbate fluid retention in CHF patients.

4. A 66-year-old woman is retiring and needs health insurance. To which agency should the employee health nurse refer her?

• A. Medicaid
• B. Medicare
• C. COBRA
• D. Private insurance

Correct answer: B

Rationale: The correct answer is B: Medicare. Medicare is the federal health insurance program for individuals aged 65 and older, so it is the most suitable option for the 66-year-old woman retiring. Medicaid (choice A) is a state and federally funded program for low-income individuals and families, not specifically for retirees. COBRA (choice C) allows employees to continue their employer-sponsored health insurance for a limited time after leaving employment. Private insurance (choice D) refers to health insurance plans purchased directly from private insurance companies.

5. A client presents to the emergency room with an acute asthma attack. What is the nurse's priority intervention?

• A. Administer bronchodilators as prescribed.
• B. Administer oxygen at 2 liters per nasal cannula.
• C. Perform chest physiotherapy.
• D. Provide emotional support to reduce anxiety.

Correct answer: A

Rationale: The correct answer is to administer bronchodilators as prescribed. During an acute asthma attack, the priority is to open the airways quickly to help the client breathe more easily. Oxygen may be needed but bronchodilators take precedence as they directly target bronchoconstriction. Chest physiotherapy is not indicated in the acute phase of asthma and may exacerbate the condition. While emotional support is important, addressing the airway obstruction takes precedence in this situation.

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