Nursing Elites

1. A healthcare provider is assessing a client who has fluid volume excess. Which of the following findings should the healthcare provider expect?

• A. Hypotension
• B. Bradycardia
• C. Crackles in the lungs
• D. Dry mucous membranes

Correct answer: C

Rationale: Crackles in the lungs are indicative of fluid accumulation in the alveoli, which is a characteristic finding in clients with fluid volume excess. The crackling sound occurs due to the presence of excess fluid in the lungs, impairing normal ventilation and gas exchange. Monitoring for crackles is essential for early detection and management of fluid overload in clients. Choices A, B, and D are incorrect because in fluid volume excess, hypervolemia leads to increased blood pressure (not hypotension), compensatory tachycardia (not bradycardia), and moist mucous membranes (not dry).

2. When planning care for a client with a pressure ulcer, which intervention should the nurse include in the plan?

• A. Massage the reddened area.
• B. Apply a donut-shaped cushion.
• C. Reposition the client every 3 hours.
• D. Use a transparent film dressing.

Correct answer: D

Rationale: The correct intervention for a client with a pressure ulcer is to use a transparent film dressing. This dressing provides a protective barrier against external contaminants while allowing for wound inspection, promoting healing. Massaging the reddened area can cause further damage to the skin and should be avoided. Donut-shaped cushions can increase pressure on the ulcer site rather than alleviate it. Repositioning the client every 2 hours is a preventive measure for pressure ulcers, but once an ulcer has developed, using a transparent film dressing is a more appropriate intervention to facilitate healing and protect the wound site.

3. A client with hypertension is being educated by a healthcare professional about lifestyle changes. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should consume foods low in potassium.
• B. I should consume foods low in sodium.
• C. I should consume foods high in saturated fats.
• D. I should consume foods high in cholesterol.

Correct answer: B

Rationale: The correct answer is B: 'I should consume foods low in sodium.' This statement indicates an understanding of managing hypertension. Excessive sodium intake can lead to increased blood pressure, so reducing sodium consumption is crucial in hypertension management to prevent complications. Choices A, C, and D are incorrect. Consuming foods low in potassium is not typically recommended for hypertension management as potassium-rich foods like fruits and vegetables can be beneficial. Consuming foods high in saturated fats and cholesterol can be detrimental to cardiovascular health and should be limited in individuals with hypertension.

4. A client has a new diagnosis of hypertension and is being taught about dietary management. Which of the following statements should be included by the healthcare provider?

• A. Increase your intake of sodium-rich foods.
• B. Decrease your intake of sodium-rich foods.
• C. Avoid foods that contain lactose.
• D. Increase your intake of dairy products.

Correct answer: B

Rationale: The correct answer is B: 'Decrease your intake of sodium-rich foods.' When managing hypertension, reducing the intake of sodium-rich foods is essential. Excessive sodium can contribute to increased blood pressure, which is why limiting its consumption is crucial to prevent complications. Choices A, C, and D are incorrect. Increasing sodium intake would exacerbate hypertension, avoiding lactose is unrelated to managing hypertension, and increasing dairy product intake does not specifically address the issue of sodium intake in hypertension management.

5. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

Similar Questions