Nursing Elites

1. A client with heart failure is on a fluid restriction. What should the nurse include in the discharge teaching?

• A. Encourage the client to drink more water to stay hydrated
• B. Monitor the client's weight daily
• C. Avoid drinking water after 6 PM
• D. Monitor fluid intake only during meals

Correct answer: B

Rationale: The correct answer is B: 'Monitor the client's weight daily.' In clients with heart failure on fluid restriction, monitoring daily weight is crucial to track fluid balance. This allows healthcare providers to assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink more water contradicts the fluid restriction; avoiding drinking water after 6 PM is not specific to managing fluid restriction; and monitoring fluid intake only during meals does not provide a comprehensive assessment of fluid balance throughout the day.

2. How should a healthcare professional assess and manage a patient with dehydration?

• A. Assess skin turgor and monitor intake/output
• B. Encourage oral fluids only
• C. Administer IV fluids immediately
• D. Check for electrolyte imbalance and administer fluids

Correct answer: A

Rationale: The correct way to assess and manage a patient with dehydration is to assess skin turgor and monitor intake/output. Skin turgor assessment helps in evaluating the degree of dehydration, while monitoring intake/output aids in maintaining fluid balance. Encouraging oral fluids only (Choice B) may not be sufficient for moderate to severe dehydration as patients may need intravenous fluids (IV) to rapidly rehydrate. Administering IV fluids immediately (Choice C) is not always the first step unless the patient is severely dehydrated. Checking for electrolyte imbalance and administering fluids (Choice D) is important but comes after assessing skin turgor and intake/output in the management of dehydration.

3. A nurse is caring for a client post-abdominal surgery who has an NG tube. The client reports nausea and a decrease in gastric output. What should the nurse do first?

• A. Turn the client onto their left side
• B. Irrigate the NG tube with sterile water
• C. Increase the suction pressure to relieve the blockage
• D. Remove the NG tube and replace it with a new one

Correct answer: B

Rationale: The correct answer is to irrigate the NG tube with sterile water first. This action helps to relieve blockages that may be causing the decrease in gastric output and nausea. Turning the client onto their left side may not directly address the issue with the NG tube. Increasing the suction pressure can further exacerbate the problem and should not be done without assessing the situation first. Removing the NG tube and replacing it with a new one is a more invasive step that should be considered only if other measures are unsuccessful.

4. What is the role of a nurse in managing a patient with acute kidney injury (AKI)?

• A. Monitor urine output and electrolyte levels
• B. Administer diuretics and restrict potassium
• C. Provide dietary education and monitor fluid intake
• D. Administer antibiotics and check for dehydration

Correct answer: A

Rationale: The correct answer is A: 'Monitor urine output and electrolyte levels.' In managing a patient with acute kidney injury (AKI), it is crucial for the nurse to monitor urine output and electrolyte levels to assess kidney function and the patient's fluid and electrolyte balance. This monitoring helps in early detection of any worsening kidney function or electrolyte imbalances. Choice B is incorrect because administering diuretics and restricting potassium may not be appropriate for all AKI patients and should be done under the direction of a healthcare provider. Choice C is also incorrect as providing dietary education and monitoring fluid intake are important but do not directly address the immediate management of AKI. Choice D is incorrect as administering antibiotics and checking for dehydration are not primary interventions for managing AKI; antibiotics are only given if there is an infection contributing to AKI, and dehydration should be managed but is not the primary role of the nurse in AKI management.

5. What is an early sign that suctioning is needed for a client with a tracheostomy?

• A. Bradycardia
• B. Irritability
• C. Hypotension
• D. Decreased oxygen saturation

Correct answer: B

Rationale: Irritability is an early sign that suctioning is needed for a client with a tracheostomy. When secretions accumulate in the airway, it can lead to discomfort and irritability in the client. Bradycardia, hypotension, and decreased oxygen saturation are usually later signs of inadequate airway clearance and oxygenation. Bradycardia may indicate severe hypoxia, while hypotension and decreased oxygen saturation are consequences of prolonged airway obstruction.

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