Nursing Elites

1. A client with heart failure is experiencing shortness of breath and swelling in the legs. What is the nurse's priority intervention?

• A. Administer prescribed diuretics
• B. Place the client in a supine position
• C. Restrict fluid intake immediately
• D. Increase the client's sodium intake

Correct answer: A

Rationale: The correct answer is A: Administer prescribed diuretics. Diuretics are prescribed to reduce fluid overload in clients with heart failure. By promoting urine output, diuretics help alleviate symptoms like shortness of breath and swelling. While placing the client in a supine position can help with breathing and fluid redistribution, administering diuretics takes precedence as it directly addresses fluid overload. Restricting fluid intake immediately may be necessary in some cases, but the immediate priority is to administer diuretics. Increasing the client's sodium intake would worsen fluid retention and is contraindicated in heart failure.

2. Which foods should a healthcare provider recommend for a child with phenylketonuria (PKU) to avoid?

• A. Fresh fruit and vegetables
• B. Foods sweetened with aspartame
• C. Bread with honey
• D. Gluten-rich bread

Correct answer: B

Rationale: The correct answer is B: 'Foods sweetened with aspartame.' Children with PKU must avoid foods containing aspartame because it breaks down into phenylalanine, which can worsen their condition. Choice A, fresh fruit and vegetables, are generally healthy and safe for individuals with PKU. Choice C, bread with honey, is also safe unless the bread contains artificial sweeteners like aspartame. Choice D, gluten-rich bread, is not specifically problematic for individuals with PKU unless it contains aspartame or other substances high in phenylalanine.

3. A client is experiencing chest pain and is prescribed nitroglycerin. What should the nurse assess before administering the medication?

• A. Monitor the client’s oxygen saturation level.
• B. Check the client’s heart rate and blood pressure.
• C. Evaluate the client’s level of consciousness.
• D. Assess the client's chest pain severity using a pain scale.

Correct answer: B

Rationale: Before administering nitroglycerin, it is crucial to check the client’s heart rate and blood pressure. Nitroglycerin can lower blood pressure and heart rate, so assessing these parameters is essential to prevent exacerbating hypotension or bradycardia. While monitoring the client’s oxygen saturation level is important in some situations, it is not the primary assessment needed before administering nitroglycerin. Evaluating the client’s level of consciousness is relevant for other conditions but not specifically necessary before giving nitroglycerin. Assessing chest pain severity using a pain scale is valuable for pain management but is not the priority assessment before administering nitroglycerin.

4. A client with cirrhosis is receiving lactulose. What is the most important assessment for the nurse to monitor?

• A. Monitor the client's ammonia levels.
• B. Monitor the client's blood glucose level.
• C. Monitor the client's potassium levels.
• D. Monitor the client's level of consciousness.

Correct answer: D

Rationale: The correct answer is to monitor the client's level of consciousness. Lactulose is used to reduce ammonia levels in hepatic encephalopathy. Monitoring the level of consciousness helps assess the effectiveness of lactulose therapy in improving the client's condition. Monitoring ammonia levels (choice A) is important, but assessing the client's response to therapy through their level of consciousness is more crucial. Blood glucose levels (choice B) and potassium levels (choice C) are not directly related to lactulose therapy for cirrhosis and hepatic encephalopathy.

5. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care?

• A. Esophagitis
• B. Leukopenia
• C. Fatigue
• D. Skin irritation

Correct answer: B

Rationale: The correct answer is B: Leukopenia. Leukopenia, or a low white blood cell count, is a critical concern in clients undergoing radiation therapy due to the increased risk of infection. While esophagitis, fatigue, and skin irritation are also potential side effects of radiation therapy, leukopenia poses a higher risk as it compromises the body's ability to fight infections effectively.

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