Nursing Elites

1. The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?

• A. Increase fluids if your mouth feels dry.
• B. More fluids are needed if you feel thirsty.
• C. Drink more fluids in the late evening hours.
• D. If you feel lethargic or confused, you need more to drink.

Correct answer: A

Rationale: The correct answer is A. An alert, older patient can self-assess for signs of dehydration like dry mouth. This instruction is appropriate as it encourages the patient to respond to early signs of dehydration. Choice B is incorrect because the thirst mechanism decreases with age and feeling thirsty may not accurately indicate the need for fluids. Choice C is incorrect as many older patients prefer to limit evening fluid intake to enhance sleep quality. Choice D is incorrect because an older adult who is lethargic or confused may not be able to accurately assess their need for fluids.

2. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?

• A. Plan low-carbohydrate and high-protein meals
• B. Engage in moderate physical activity for an hour daily
• C. Keep a record of food and drinks consumed daily
• D. Participate in a group exercise class 3 times a week

Correct answer: C

Rationale: A BMI of 30 indicates the patient is obese. The first step in a weight loss plan should be to keep a food journal to track calorie intake, which can help in meal planning and creating a workout routine. Choice (A) suggests a dietary approach, which is important but not the first step. Choice (B) recommends strenuous activity, which may not be suitable for everyone and is not the initial step. Choice (D) involves group exercise, which can be beneficial but is not the primary action to take at the beginning of a weight loss plan.

3. A patient who is taking a potassium-wasting diuretic for the treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?

• A. Assess for facial muscle spasms.
• B. Ask the patient about loose stools.
• C. Suggest that the patient avoid orange juice with meals.
• D. Ask the healthcare provider to order a basic metabolic panel.

Correct answer: D

Rationale: Generalized weakness is a sign of hypokalemia, a potential side effect of potassium-wasting diuretics. By requesting a basic metabolic panel, the nurse can assess the patient's potassium levels. Facial muscle spasms are associated with hypocalcemia, not hypokalemia. Advising the patient to avoid orange juice, which is high in potassium, would be counterproductive if the patient is hypokalemic. Loose stools are typically seen in hyperkalemia, not hypokalemia.

4. A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?

• A. Obtain the baseline weight
• B. Check the patient’s blood pressure
• C. Draw blood for serum electrolyte levels
• D. Ask about any extremity numbness or tingling

Correct answer: B

Rationale: The correct answer is to check the patient’s blood pressure. Given the patient's symptoms of frequent, watery stools, there is a concern for fluid volume deficit. Assessing the blood pressure helps determine the patient's perfusion status, which is crucial in managing fluid volume deficits. While obtaining baseline weight, drawing blood for serum electrolyte levels, and asking about extremity numbness or tingling are important assessments, checking the blood pressure takes precedence as it provides immediate information on the patient's circulatory status.

5. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?

• A. Ask the wife how she would like to participate in the client's care
• B. Provide the wife with information about hospice
• C. Encourage the wife to visit after painful treatments are completed
• D. Refer the wife to a support group for family members of those dying of cancer

Correct answer: A

Rationale: The most beneficial nursing intervention in this situation is to ask the wife how she would like to participate in the client's care. Involving the spouse in the care of the terminally ill client can provide comfort, support, and a sense of contribution during a challenging time. Providing information about hospice (B) is important but may not be the immediate priority. Encouraging the wife to visit after treatments are completed (C) may delay her involvement in the care. Referring her to a support group (D) is a good idea but might be more suitable at a later stage.

Similar Questions