Nursing Elites

1. A client with cirrhosis is experiencing ascites. Which dietary instruction should the nurse provide?

• A. Increase protein intake.
• B. Limit fluid intake to 1500 mL/day.
• C. Consume a low-sodium diet.
• D. Take a daily multivitamin.

Correct answer: C

Rationale: For a client with cirrhosis experiencing ascites, the nurse should instruct them to consume a low-sodium diet. This dietary modification helps reduce fluid retention and manage ascites by decreasing the amount of sodium in the body, which helps prevent fluid accumulation in the abdomen. Limiting sodium intake is crucial in managing ascites and preventing further complications in clients with cirrhosis.

2. When caring for a client with acute pancreatitis, what intervention is most appropriate?

• A. Encourage a high-protein diet.
• B. Administer pain medication as needed.
• C. Provide small, frequent meals.
• D. Increase oral fluid intake.

Correct answer: B

Rationale: Administering pain medication as needed is the most appropriate intervention for a client with acute pancreatitis. Pain management is crucial as pancreatitis can cause severe and debilitating pain. Providing pain relief is essential to improve the client's comfort and well-being.

3. A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improvement (QI) projects. What response by the precepting nurse is best?

• A. All staff nurses are required to participate in quality improvement projects.
• B. Even as a new nurse, you can implement activities designed to improve care.
• C. It's easy to identify which indicators should be used to measure quality improvement.
• D. You should ask to be assigned to the research and quality committee.

Correct answer: B

Rationale: The best response is to encourage the newly graduated nurse to actively participate in quality improvement initiatives. Being new does not preclude one from contributing to improving care processes and outcomes. By engaging in small activities focused on quality improvement, the new nurse can start making a positive impact and learn valuable skills early in their career.

4. While suctioning the endotracheal tube of a client on a ventilator, the nurse notices an increase in the client's heart rate from 86/min to 110/min, with irregularity. What should the nurse do next?

• A. Obtain a cardiology consult.
• B. Suction the client less frequently.
• C. Administer an antidysrhythmic medication.
• D. Perform pre-oxygenation prior to suctioning.

Correct answer: D

Rationale: When a client's heart rate increases and becomes irregular during suctioning of an endotracheal tube, it indicates potential hypoxemia. Performing pre-oxygenation before suctioning helps prevent hypoxemia and subsequent dysrhythmias. This intervention ensures that the client has adequate oxygen reserves before the procedure, reducing the risk of complications related to suctioning.

5. A client is receiving oxygen therapy via nasal cannula. Which finding indicates that the therapy is effective?

• A. The client is able to ambulate in the hall without dyspnea.
• B. The client has a respiratory rate of 24 breaths per minute.
• C. The client's oxygen saturation is 92%.
• D. The client has a productive cough.

Correct answer: A

Rationale: The correct answer is A. Effective oxygen therapy should improve the client's ability to perform activities without dyspnea. This indicates that the oxygen therapy is adequately supporting the client's respiratory needs. An oxygen saturation of 92% may suggest the need for a higher flow rate to improve oxygenation. A respiratory rate of 24 breaths per minute is elevated, indicating potential respiratory distress. A productive cough does not necessarily indicate effective oxygen therapy, as it is a symptom of respiratory irritation or infection, not oxygenation status.

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