Nursing Elites

1. A client with a new diagnosis of heart failure is receiving teaching from a nurse. Which of the following instructions should the nurse include?

• A. Limit sodium intake to 4 grams per day.
• B. Weigh yourself daily to monitor for fluid retention.
• C. Drink 2 liters of water each day.
• D. Increase physical activity gradually.

Correct answer: B

Rationale: The correct answer is B. Weighing oneself daily is crucial in monitoring fluid retention, a key aspect in managing heart failure. This helps in detecting early signs of fluid buildup, prompting timely interventions. Choice A is incorrect as the recommended sodium intake for heart failure clients is usually lower, around 2-3 grams daily. Choice C is incorrect because excessive water intake can worsen fluid retention in heart failure. Choice D is incorrect as clients with heart failure should consult healthcare providers before significantly altering their physical activity levels.

2. A client with osteoporosis is being taught about dietary management. Which of the following foods should be recommended?

• A. Almonds
• B. Spinach
• C. Yogurt
• D. Carrots

Correct answer: C

Rationale: Yogurt is a calcium-rich food that helps strengthen bones and should be recommended to clients with osteoporosis. Almonds, spinach, and carrots do not provide as much calcium as yogurt and are not as beneficial for individuals with osteoporosis.

3. A nurse is reviewing the medical record of a client with major depressive disorder who is taking fluoxetine. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 80/min
• B. Blood pressure 130/80 mm Hg
• C. Weight gain of 2.2 kg (5 lb) in 1 week
• D. Temperature of 37.2°C (99°F)

Correct answer: C

Rationale: The correct answer is C. A weight gain of 2.2 kg (5 lb) in 1 week can indicate fluid retention, a serious side effect of fluoxetine that should be reported to the provider. Choices A, B, and D are within normal ranges and are not alarming findings that would require immediate reporting to the provider. A heart rate of 80/min, blood pressure of 130/80 mm Hg, and a temperature of 37.2°C (99°F) are all within normal limits and not typically concerning in a client taking fluoxetine.

4. How should a healthcare professional manage a patient with fluid overload in heart failure?

• A. Monitor daily weight
• B. Check for edema
• C. Monitor intake and output
• D. Administer diuretics

Correct answer: A

Rationale: Monitoring daily weight is crucial in managing a patient with fluid overload in heart failure. Weight fluctuations can indicate fluid retention or loss, guiding healthcare professionals in adjusting treatment. While checking for edema (Choice B) and monitoring intake and output (Choice C) are important aspects of patient care, they are not as direct in assessing fluid overload as daily weight monitoring. Administering diuretics (Choice D) is a treatment option based on the assessment of fluid overload, making it a secondary intervention compared to monitoring weight.

5. A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse expect?

• A. Barrel-shaped chest
• B. Bradycardia
• C. Increased respiratory rate
• D. Tracheal deviation

Correct answer: C

Rationale: Corrected Rationale: An increased respiratory rate is a common finding in clients with ARDS as the body attempts to compensate for impaired gas exchange. Barrel-shaped chest (Choice A) is associated with conditions like COPD, not ARDS. Bradycardia (Choice B) is unlikely in ARDS due to the body's compensatory mechanisms to improve oxygenation. Tracheal deviation (Choice D) is not typically seen in ARDS and is more suggestive of other respiratory conditions.

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