Nursing Elites

1. In what order should the unit manager implement interventions to address the UAP’s behavior after they leave the unit without notifying the staff?

• A. Note date and time of the behavior.
• B. Discuss the issue privately with the UAP.
• C. Plan for scheduled break times.
• D. Evaluate the UAP for signs of improvement.

Correct answer: A

Rationale: The correct order for the unit manager to implement interventions to address the UAP's behavior is to first note the date and time of the behavior. Proper documentation is crucial as it provides a factual record of the incident. This documentation can be used to address the behavior effectively and to track any patterns or improvements in the future. Discussing the issue with the UAP privately (choice B) should come after documenting the behavior. Planning for scheduled break times (choice C) is unrelated to the situation described and does not address the UAP's behavior of leaving without notifying the staff. Evaluating the UAP for signs of improvement (choice D) can only be done effectively after the behavior has been addressed and interventions have been implemented.

2. During discharge teaching, the nurse discusses the parameters for weight monitoring with a client recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?

• A. Weigh at the same time every day
• B. Report weight gain of 2 pounds (0.9kg) in 24 hours
• C. Maintain a daily weight record
• D. Limit dietary salt intake

Correct answer: B

Rationale: The correct answer is B. Reporting a weight gain of 2 pounds in 24 hours is crucial for detecting fluid retention or worsening heart failure. This rapid weight gain indicates possible fluid overload, which can be a sign of worsening HF. Option A is not as critical as the timing of weighing can vary. Option C is important for tracking trends but does not emphasize the significance of a sudden weight gain. Option D is relevant for managing HF but does not address the immediate need for reporting rapid weight gain.

3. A client morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Restrict daily fluid intake to 1500 ml
• B. Weight the client every morning
• C. Maintain accurate intake and output
• D. Administer prescribed diuretic

Correct answer: D

Rationale: Administering a prescribed diuretic is the most important intervention in this scenario as the client is presenting signs of fluid overload and heart failure. Diuretics help reduce fluid retention in the body, alleviating symptoms like edema and crackles. Restricting fluid intake may be necessary in some cases, but in this acute situation, addressing the immediate fluid overload with a diuretic takes precedence. Weighing the client daily and maintaining accurate intake and output are important aspects of monitoring, but they do not directly address the urgent need to manage fluid overload.

4. A client prescribed warfarin is being taught about dietary modifications by a nurse. Which statement by the client indicates understanding of the teaching?

• A. ''I need to avoid foods high in vitamin C.''
• B. ''I should eat a consistent amount of vitamin K each day.''
• C. ''I can eat as many leafy greens as I want.''
• D. ''I should not worry about any changes in my diet.''

Correct answer: B

Rationale: The correct answer is B. Consistency in vitamin K intake is crucial for clients on warfarin to maintain stable anticoagulation levels. Option A is incorrect as vitamin C does not directly interact with warfarin. Option C is incorrect because although leafy greens are high in vitamin K, excessive consumption can affect warfarin's effectiveness. Option D is incorrect as any changes in diet, particularly in vitamin K intake, can impact the efficacy of warfarin.

5. An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client used to run a year ago, his spouse states that the client no longer runs but sits and watches television most of the day. Which is most important for the nurse to include in this client’s plan of care for today?

• A. Assist the client in identifying goals for the day
• B. Encourage the client to participate in a team sport for one hour
• C. Schedule the client for a group session that focuses on self-esteem
• D. Help the client develop a list of daily affirmations

Correct answer: A

Rationale: Assisting the client in identifying goals for the day is the most important aspect of the plan of care for a client with severe depression. Setting achievable daily goals helps engage the client in activities and promotes a sense of accomplishment, which can contribute to gradual improvement in their condition. Encouraging participation in team sports may be overwhelming for a client with severe depression as it requires a significant level of energy and motivation that the client may not possess at this time. Group sessions focusing on self-esteem and daily affirmations are beneficial interventions, but they may not have an immediate impact compared to setting achievable daily goals that can provide a sense of purpose and achievement for the client.

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