Nursing Elites

1. A nurse is caring for a 73-year-old male client with Alzheimer's disease. Which action should the nurse take to enhance the client's nutritional intake?

• A. Encourage the client to eat large meals in one sitting.
• B. Offer the client frequent snacks of foods he enjoys.
• C. Provide the client with foods high in fiber to improve digestion.
• D. Discourage eating late at night to prevent weight gain.

Correct answer: B

Rationale: Offering frequent snacks of foods the client enjoys is the most appropriate action to enhance the nutritional intake of a client with Alzheimer's disease. This approach helps to ensure that the client receives an adequate amount of nutrients throughout the day, especially when larger meals might be challenging for individuals with Alzheimer's. Encouraging large meals in one sitting (Choice A) may overwhelm the client and lead to decreased food intake. While foods high in fiber (Choice C) are beneficial for digestion, the primary focus should be on providing foods the client enjoys to increase intake. Discouraging eating late at night (Choice D) is not directly related to enhancing nutritional intake in this scenario.

2. A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take?

• A. Instruct the client to use a moisturizer immediately after the bath
• B. Advise the client to take shorter baths with less water
• C. Suggest taking antihistamines for the pruritus
• D. Encourage the client to use cooler water and apply calamine lotion after soaking

Correct answer: D

Rationale: In this situation, the client's pruritus (itching) is likely exacerbated by hot baths, which can worsen the itching sensation. Using cooler water will help soothe the skin and reduce pruritus. Additionally, applying calamine lotion after soaking can provide further relief. Instructing the client to use a moisturizer immediately after the bath (Choice A) may not address the root cause of pruritus aggravated by hot baths. Advising the client to take shorter baths with less water (Choice B) might not be as effective in relieving the itching sensation caused by cirrhosis. Suggesting antihistamines for the pruritus (Choice C) may not directly address the impact of hot baths on the client's discomfort.

3. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

• A. Allow the client to melt ice chips in the mouth
• B. Provide mints to freshen the breath
• C. Perform frequent oral care with a tooth sponge
• D. Swab the mouth with glycerin swabs

Correct answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this scenario. This helps maintain comfort and prevent dryness in clients with nasogastric tubes. Allowing the client to melt ice chips in the mouth may not address oral care needs effectively. Providing mints to freshen the breath is not the priority when the client needs oral care. Swabbing the mouth with glycerin swabs may not be as effective as performing thorough oral care with a tooth sponge.

4. While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

• A. White blood cell count
• B. Hemoglobin
• C. Serum creatinine
• D. Culture for sensitive organisms

Correct answer: D

Rationale: Purulent drainage suggests an infection at the wound site. Reviewing the culture and sensitivity results will guide appropriate antibiotic treatment by identifying the causative organisms and their antibiotic sensitivities. Elevated white blood cells indicate infection but do not specify the organism. Creatinine and hemoglobin values are unrelated to wound infections.

5. What might be suggested to a client with fibrocystic breasts in an attempt to help relieve symptoms?

• A. Increase intake of high-calcium foods in your diet
• B. Wear a supportive bra during the day and at night
• C. Take over-the-counter pain relievers
• D. Perform regular breast massage

Correct answer: B

Rationale: The correct answer is B: 'Wear a supportive bra during the day and at night.' Wearing a supportive bra is essential for individuals with fibrocystic breasts as it helps relieve discomfort by providing necessary support to reduce strain on breast tissue. Option A is incorrect as high-calcium foods are not directly related to symptom relief in fibrocystic breasts. Option C is not the first-line recommendation and may not address the underlying issue. Option D, performing regular breast massage, is not typically recommended and may not provide significant relief for fibrocystic breast symptoms.

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