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. A client has a new prescription for furosemide. Which of the following instructions should the nurse include during discharge teaching?

• A. Avoid foods high in potassium.
• B. Monitor weight daily.
• C. Take the medication with food.
• D. Increase salt intake.

Correct answer: B

Rationale: Monitoring weight daily is crucial when taking furosemide to detect fluid retention or loss. Furosemide is a diuretic that helps the body get rid of excess water and salt through urine. Changes in weight can indicate fluid shifts, which could be a sign of inadequate response to the medication or worsening condition. Therefore, monitoring weight daily is essential to assess the effectiveness of furosemide therapy and detect any potential issues early on. Choices A, C, and D are incorrect. Avoiding foods high in potassium is more relevant for clients taking potassium-sparing diuretics, not furosemide. Taking furosemide with food is not necessary, as it can be taken with or without food. Increasing salt intake is contradictory to the purpose of furosemide, which aims to eliminate excess salt from the body.

3. During discharge instructions, a client with a new prescription for a metered-dose inhaler (MDI) states, 'I will shake the inhaler before each use.' Which of the following client statements indicates an understanding of the teaching?

• A. I will shake the inhaler before each use.
• B. I will use the inhaler immediately after meals.
• C. I will inhale the medication quickly.
• D. I will clean the mouthpiece with alcohol.

Correct answer: A

Rationale: The correct answer is A because shaking the inhaler before each use ensures that the medication is properly mixed, which is essential for effective administration. This action helps to disperse the medication evenly, enhancing its efficacy when inhaled. Proper mixing through shaking prevents inconsistent dosing and ensures that the client receives the correct amount of medication with each use.

4. What action should a healthcare provider take for a client with a new colostomy?

• A. Empty the colostomy bag when it is half full.
• B. Place aspirin in the colostomy bag to decrease odor.
• C. Use sterile technique when caring for the stoma.
• D. Change the pouch every 8 hours.

Correct answer: A

Rationale: Emptying the colostomy bag when it is half full is crucial to prevent leakage and detachment from the skin. This practice helps to maintain the integrity of the colostomy system, reducing the risk of skin irritation and odor. It is essential for client comfort and overall stoma care.

5. A client is postoperative following abdominal surgery. Which of the following actions should be taken to prevent respiratory complications?

• A. Instruct the client to exhale into an incentive spirometer
• B. Reposition the client every 8 hours
• C. Assist the client with early ambulation
• D. Maintain the client on bed rest for the first 48 hours

Correct answer: C

Rationale: Assisting the client with early ambulation is crucial in preventing respiratory complications after abdominal surgery. Early ambulation helps to prevent conditions like atelectasis and pneumonia by promoting lung expansion and preventing pooling of respiratory secretions. It also aids in improving circulation, reducing the risk of deep vein thrombosis, and enhancing overall recovery. Instructing the client to exhale into an incentive spirometer (Choice A) is beneficial for lung expansion but is more focused on respiratory therapy rather than preventing complications. Repositioning the client every 8 hours (Choice B) is important for preventing pressure ulcers but is not directly related to preventing respiratory complications. Maintaining the client on bed rest for the first 48 hours (Choice D) can lead to complications such as atelectasis, pneumonia, and deep vein thrombosis due to decreased lung expansion and mobility.

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