Nursing Elites

1. A nurse is caring for a client who is constipated. What intervention is most appropriate?

• A. Administer a laxative to relieve discomfort
• B. Encourage the client to increase dietary fiber intake
• C. Encourage the client to rest until symptoms resolve
• D. Administer a stool softener as prescribed

Correct answer: B

Rationale: The most appropriate intervention for constipation is to encourage the client to increase dietary fiber intake. Fiber helps promote bowel movements and relieve constipation by adding bulk to the stool. Administering a laxative (Choice A) should not be the first-line intervention as it can lead to dependence. Encouraging rest (Choice C) is not directly helpful in relieving constipation. While administering a stool softener (Choice D) can be beneficial, increasing fiber intake is generally preferred as the initial intervention.

2. While caring for a client with an IV infusion who develops redness and warmth at the IV site, what is the most appropriate intervention?

• A. Elevate the IV site and apply an ice pack
• B. Administer an anti-inflammatory medication
• C. Apply a cold compress to the IV site
• D. Discontinue the IV and notify the provider

Correct answer: D

Rationale: The correct intervention when a client develops redness and warmth at the IV site, indicating phlebitis, is to discontinue the IV and notify the provider. This is crucial to prevent further complications. Elevating the IV site and applying an ice pack (Choice A) may not address the underlying issue of phlebitis. Administering an anti-inflammatory medication (Choice B) is not the primary intervention for phlebitis. Applying a cold compress (Choice C) may provide temporary relief but does not address the need to discontinue the IV when phlebitis occurs.

3. A nurse is preparing a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report?

• A. Hgb 12.8 g/dl.
• B. Potassium 4.2 mEq/L.
• C. RBC 4.4 million/mm3.
• D. Platelets 100,000/mm3.

Correct answer: D

Rationale: The correct answer is D: "Platelets 100,000/mm3." A platelet count of 100,000/mm3 is low and increases the client's risk for bleeding, which is crucial information to communicate during the change-of-shift report. Choices A, B, and C provide values within normal ranges and are not directly related to the client's postoperative status or risk for complications. Therefore, they are not the priority information to include in the report.

4. Which dietary restriction should be taught to a client with chronic kidney disease?

• A. Increase potassium-rich foods
• B. Limit phosphorus and potassium intake
• C. Encourage increased protein intake
• D. Increase fluid intake

Correct answer: B

Rationale: The correct answer is B: Limit phosphorus and potassium intake. In chronic kidney disease, the kidneys are unable to effectively filter these minerals from the blood, leading to their accumulation and potential complications. Restricting phosphorus and potassium intake is crucial in managing the progression of the disease. Choice A is incorrect as increasing potassium-rich foods can worsen the condition. Choice C is also incorrect as excessive protein intake can put more strain on the kidneys. Choice D is not the priority; rather, fluid intake should be monitored based on individual needs and stage of kidney disease.

5. How should a healthcare professional assess a patient with fluid overload?

• A. Monitor weight and assess for edema
• B. Monitor blood pressure and auscultate lung sounds
• C. Assess for jugular venous distention
• D. Monitor oxygen saturation and check for fluid retention

Correct answer: A

Rationale: The correct way to assess a patient with fluid overload is by monitoring weight and assessing for edema. Weight monitoring helps in detecting fluid retention, and edema is a visible sign of excess fluid accumulation. Although monitoring blood pressure and auscultating lung sounds are important assessments in heart failure, they are not specific to fluid overload. Assessing for jugular venous distention is more indicative of right-sided heart failure rather than fluid overload. Monitoring oxygen saturation and checking for fluid retention are not primary assessments for fluid overload.

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