Nursing Elites

1. A nurse is reviewing the medical records of a client with chronic heart failure. What dietary recommendation should the nurse make?

• A. Follow a 3g sodium diet.
• B. Drink at least 3 liters of fluid per day.
• C. Place the client's lower extremities on two pillows.
• D. Maintain the client's oxygen saturation at 89%.

Correct answer: A

Rationale: The correct answer is A: Follow a 3g sodium diet. For clients with chronic heart failure, limiting sodium intake is crucial to prevent fluid retention and exacerbation of heart failure symptoms. High sodium intake can lead to fluid buildup, causing the heart to work harder. Choices B, C, and D are incorrect. Drinking excessive fluid can worsen fluid retention in heart failure, elevating the workload of the heart. Placing the client's lower extremities on two pillows is a positioning intervention to alleviate edema, not a dietary recommendation. Maintaining oxygen saturation at 89% is more related to respiratory status rather than dietary management of chronic heart failure.

2. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

• A. I can give you information about respite care if you are interested.
• B. You should consider taking a sleeping pill before bed each night.
• C. It must be difficult taking care of someone who is terminally ill.
• D. You are doing a great job taking care of your mother.

Correct answer: A

Rationale: Offering information about respite care is a therapeutic response that supports the caregiver. Choice B suggests a quick fix with sleeping pills without addressing the underlying issue of caregiver stress. Choice C, though empathetic, does not offer practical assistance or support. Choice D, while positive, does not address the son's need for rest and support.

3. A nurse in a mental health unit is planning room assignments for four clients. Which of the following clients should be closest to the nurse's station?

• A. A client who has an anxiety disorder and is experiencing moderate anxiety.
• B. A client who has somatic symptom disorder and reports chronic pain.
• C. A client who has depressive disorder and reports feeling hopeless.
• D. A client who has bipolar disorder and impaired social interactions.

Correct answer: D

Rationale: A client with bipolar disorder and impaired social interactions should be placed closest to the nurse's station for closer monitoring. Clients with bipolar disorder may experience mood swings, including manic episodes that can lead to impulsive behaviors or aggression. Placing such a client near the nurse's station allows for quick intervention and monitoring of their social interactions, especially if they are impaired. The other options, such as anxiety disorder, somatic symptom disorder, and depressive disorder, do not inherently require immediate proximity to the nurse's station based on the information provided.

4. A client is receiving discharge teaching about a new prescription for ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should take this medication with milk.
• B. I should expect my stools to turn black.
• C. I should avoid eating oranges while taking this medication.
• D. I will take this medication on an empty stomach.

Correct answer: B

Rationale: The correct answer is B. When taking ferrous sulfate, clients should expect their stools to turn black, which is a normal side effect due to the iron content. Choice A is incorrect because ferrous sulfate should not be taken with milk as it can decrease its absorption. Choice C is incorrect because vitamin C-rich foods like oranges can actually enhance the absorption of iron. Choice D is incorrect because ferrous sulfate is usually recommended to be taken on an empty stomach for better absorption.

5. A client is receiving radiation therapy to the head and neck. Which of the following interventions should the nurse include?

• A. Instruct the client to use an alcohol-free mouthwash.
• B. Apply heat packs to the radiation site.
• C. Provide a diet low in carbohydrates.
• D. Avoid exposure to direct sunlight during treatment.

Correct answer: D

Rationale: The correct intervention for a client receiving radiation therapy to the head and neck is to avoid exposure to direct sunlight. Direct sunlight should be avoided to protect the skin from further irritation and damage caused by the radiation therapy. Instructing the client to use an alcohol-free mouthwash is important to prevent irritation and maintain oral hygiene, making choice A incorrect. Applying heat packs to the radiation site is contraindicated as heat can further aggravate the skin, making choice B incorrect. Providing a diet low in carbohydrates is not directly related to radiation therapy to the head and neck, so choice C is also incorrect.

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