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 client receiving total parenteral nutrition (TPN) is experiencing nausea and vomiting. What is the nurse's first action?

• A. Check the client's blood glucose level.
• B. Decrease the rate of TPN infusion.
• C. Administer an antiemetic as prescribed.
• D. Check the client's TPN bag for solution accuracy.

Correct answer: D

Rationale: The correct first action for the nurse to take when a client receiving TPN is experiencing nausea and vomiting is to check the client's TPN bag for solution accuracy. This is crucial to ensure that the correct solution is being administered and to address any potential errors. Checking the blood glucose level or administering an antiemetic may be necessary interventions but addressing the TPN bag's accuracy should be the priority to prevent any complications related to incorrect TPN solution.

3. A client with asthma is experiencing wheezing. What is the nurse’s priority intervention?

• A. Administer a bronchodilator immediately.
• B. Increase the client's oxygen flow rate.
• C. Perform a chest x-ray to assess lung function.
• D. Place the client in a high Fowler’s position.

Correct answer: A

Rationale: The correct answer is A: Administer a bronchodilator immediately. Wheezing in a client with asthma indicates bronchoconstriction, which can compromise airflow. Administering a bronchodilator is the priority intervention as it helps to open the airways, relieve bronchoconstriction, and improve breathing. Increasing the oxygen flow rate (choice B) may be necessary but is not the priority when the airways are constricted. Performing a chest x-ray (choice C) is not the immediate action needed in this situation. Placing the client in a high Fowler's position (choice D) may provide some relief, but administering a bronchodilator to address the bronchoconstriction is the priority intervention.

4. The nurse is developing a plan of care for a client who reports tingling in the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client?

• A. The client will walk 30 minutes three times a week
• B. The client will demonstrate understanding of proper shoe fit
• C. The client will perform foot care daily
• D. The client's blood pressure readings will be less than 160/90 mmHg

Correct answer: D

Rationale: Controlling blood pressure is critical in managing peripheral vascular disease, as elevated pressure can exacerbate vascular damage and complications. While foot care, shoe fit, and exercise are important, lowering blood pressure is a primary goal. Proper blood pressure management helps in preventing further damage to the blood vessels and reduces the risk of complications associated with peripheral vascular disease, making it the most crucial outcome to include in the plan of care for this client.

5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration status?

• A. Urine specific gravity of 1.040.
• B. Systolic blood pressure decreases by 10 points when standing.
• C. The client denies feeling thirsty.
• D. Skin turgor exhibits tenting on the forearm.

Correct answer: A

Rationale: In the context of fluid volume deficit and dehydration, urine specific gravity of 1.040 is the best indicator of hydration status. High urine specific gravity indicates concentrated urine, suggesting dehydration. Choice B, systolic blood pressure decreasing when standing, is more indicative of orthostatic hypotension rather than hydration status. Choice C, denial of thirst, is a subjective finding and may not always reflect actual hydration status. Choice D, skin turgor exhibiting tenting on the forearm, is a sign of dehydration but may not be as accurate as urine specific gravity in assessing hydration status.

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