Nursing Elites

1. When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?

• A. Encourage the client and family to be active partners.
• B. Instruct the client to monitor hand hygiene in caregivers.
• C. Offer the family the opportunity to stay with the client.
• D. Advise the client to always wear their armband.

Correct answer: A

Rationale: Encouraging the client and family to be active partners in their healthcare is crucial for promoting safety. When clients and families actively participate, they are more likely to advocate for themselves, ask questions, and be engaged in their care, leading to better outcomes and reduced risks.

2. A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?

• A. The client demonstrates a good understanding of stoma care.
• B. The client has joined a book club that meets at the library.
• C. Family members take turns assisting with stoma care.
• D. Skin around the stoma is intact without signs of infection.

Correct answer: B

Rationale: The client joining a book club that meets outside the home and requires him or her to go out in public is the best indicator that goals for Impaired Self-Esteem are being met. This social activity indicates an improvement in self-confidence and willingness to engage with others, which are essential aspects of self-esteem. The other choices, while positive, do not directly address self-esteem concerns related to social interaction and confidence.

3. A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?

• A. Perform suctioning for up to four passes.
• B. Apply suction to the catheter when advancing it into the trachea.
• C. Preoxygenate the client with 100% oxygen for up to 3 min.
• D. Limit each suction pass to 25 seconds.

Correct answer: C

Rationale:

4. A client takes atorvastatin (Lipitor), with laboratory results showing a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?

• A. Ask if the client eats grapefruit.
• B. Assess the client for dehydration.
• C. Facilitate admission to the hospital.
• D. Obtain a random urinalysis.

Correct answer: A

Rationale: There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. The client has elevated renal laboratory results, indicating kidney involvement. The nurse should ask if the client consumes grapefruit or grapefruit juice. While dehydration can elevate BUN, the increase in creatinine is more specific for kidney injury.

5. A client with cirrhosis is experiencing ascites. Which dietary instruction should the nurse provide?

• A. Increase protein intake.
• B. Limit fluid intake to 1500 mL/day.
• C. Consume a low-sodium diet.
• D. Take a daily multivitamin.

Correct answer: C

Rationale: For a client with cirrhosis experiencing ascites, the nurse should instruct them to consume a low-sodium diet. This dietary modification helps reduce fluid retention and manage ascites by decreasing the amount of sodium in the body, which helps prevent fluid accumulation in the abdomen. Limiting sodium intake is crucial in managing ascites and preventing further complications in clients with cirrhosis.

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