Nursing Elites

1. A nurse is caring for a client who has severe preeclampsia. Which of the following interventions should the nurse include in the plan of care?

• A. Administer magnesium sulfate.
• B. Place the client in the left lateral position.
• C. Monitor intake and output.
• D. Provide a low-sodium diet.

Correct answer: C

Rationale: The correct intervention for a client with severe preeclampsia is to monitor intake and output. This is crucial to assess kidney function, fluid balance, and detect any signs of deterioration. Administering magnesium sulfate is indicated for seizure prophylaxis in severe preeclampsia, but it is not the primary intervention related to care planning. Placing the client in the left lateral position is not a specific intervention for managing preeclampsia. Providing a low-sodium diet is not typically recommended for clients with severe preeclampsia as sodium restriction is not a primary treatment modality for this condition.

2. A client with a new diagnosis of Crohn's disease is being taught about dietary management by a nurse. Which of the following instructions should the nurse include?

• A. Eat foods that are high in fiber.
• B. Avoid dairy products to reduce diarrhea.
• C. Eat small, frequent meals to reduce symptoms.
• D. You should increase your intake of whole grains.

Correct answer: C

Rationale: The correct instruction the nurse should include is to advise the client to eat small, frequent meals to reduce symptoms of Crohn's disease. This eating pattern can help manage symptoms by reducing the workload on the digestive system. Choice A is incorrect because foods high in fiber can aggravate symptoms in Crohn's disease. Choice B is incorrect because not all individuals with Crohn's disease need to avoid dairy products, and it is not a universal recommendation. Choice D is incorrect because increasing whole grains may not be suitable for everyone with Crohn's disease, as it can worsen symptoms in some cases.

3. How should fluid balance in a patient with heart failure be monitored?

• A. Monitor daily weight
• B. Monitor input and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: The correct answer is to monitor daily weight. Daily weight monitoring is crucial in assessing fluid balance in patients with heart failure because sudden weight gain can indicate fluid retention. Monitoring input and output (choice B) is important but may not provide a complete picture of fluid balance. Checking for edema (choice C) is a sign of fluid accumulation but may not be as accurate as daily weight monitoring. Monitoring blood pressure (choice D) is important in heart failure management but does not directly assess fluid balance.

4. What is the priority nursing intervention for a patient with a stage 3 pressure ulcer?

• A. Apply hydrocolloid dressing
• B. Provide wound debridement
• C. Change the dressing daily
• D. Elevate the affected area

Correct answer: A

Rationale: The correct answer is to apply a hydrocolloid dressing. Stage 3 pressure ulcers are characterized by full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, which requires a moist environment for healing. Hydrocolloid dressings help maintain a moist wound environment, promote healing, and provide protection. Providing wound debridement may be necessary but is not the priority intervention at this stage. Changing the dressing daily is important for wound care but not the priority over creating an optimal healing environment. Elevating the affected area can help with circulation and reduce swelling, but it is not the priority intervention for a stage 3 pressure ulcer.

5. A client with lactose intolerance and has eliminated dairy products from his diet should increase consumption of which of the following foods?

• A. Spinach
• B. Peanut butter
• C. Ground beef
• D. Carrots

Correct answer: A

Rationale: Spinach is the correct answer because it is a good source of calcium. Since the client has eliminated dairy products due to lactose intolerance, which are a common source of calcium, increasing spinach consumption can help compensate for the lost calcium. Peanut butter, ground beef, and carrots are not significant sources of calcium and therefore not the best choice for this client.

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