Nursing Elites

1. What is the priority intervention for a patient with fluid overload?

• A. Administer diuretics
• B. Administer IV fluids
• C. Provide oral fluids
• D. Provide chest physiotherapy

Correct answer: A

Rationale: The correct answer is to administer diuretics. Diuretics help reduce excess fluid in cases of fluid overload, making it the priority intervention. Administering additional IV fluids (choice B) would exacerbate the problem by adding more fluid. Providing oral fluids (choice C) is not the priority as the excess fluid needs to be removed first. Chest physiotherapy (choice D) is not the primary intervention for fluid overload.

2. A nurse is caring for a client who has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?

• A. Apply the patch to the same location each time.
• B. Rotate the patch site daily to avoid skin irritation.
• C. Apply the patch in the morning and remove it at bedtime.
• D. Keep the patch on at all times, even during a bath.

Correct answer: C

Rationale: The correct answer is to apply the nitroglycerin transdermal patch in the morning and remove it at bedtime. This schedule helps prevent tolerance to the medication. Choice A is incorrect because the patch should be rotated to different sites to prevent skin irritation. Choice B is incorrect as daily rotation is recommended, not daily application to the same site. Choice D is incorrect as the patch should be removed during a bath as it may decrease the efficacy of the medication.

3. A client with a colostomy needs optimal skin integrity. What action should the nurse take to promote this?

• A. Cleanse the peristomal skin with alcohol.
• B. Change the colostomy pouch every 3 days.
• C. Use a barrier cream to protect the skin from the pouch contents.
• D. Cleanse the stoma with hydrogen peroxide.

Correct answer: C

Rationale: To promote optimal skin integrity in a client with a colostomy, using a barrier cream to protect the skin from the irritating effects of the colostomy pouch contents is essential. Cleansing the peristomal skin with alcohol (Choice A) can be too harsh and drying for the skin. Changing the colostomy pouch every 3 days (Choice B) is important for hygiene but using a barrier cream is more directly related to skin protection. Cleaning the stoma with hydrogen peroxide (Choice D) is not recommended as it can be too abrasive for the sensitive stoma area.

4. A nurse is planning care for a client who practices Orthodox Judaism and is observing the Passover holiday. Which of the following actions should the nurse include in the plan of care?

• A. Provide chicken with cream sauce.
• B. Avoid serving fish with fins and scales.
• C. Provide unleavened bread.
• D. Avoid serving foods containing lamb.

Correct answer: C

Rationale: During the Passover holiday, individuals practicing Orthodox Judaism follow dietary restrictions that include avoiding leavened bread. Providing unleavened bread aligns with these restrictions and ensures the client's observance of the holiday. Choices A, B, and D are incorrect because serving chicken with cream sauce, avoiding fish with fins and scales, and avoiding foods containing lamb are not specific dietary requirements related to observing Passover in Orthodox Judaism.

5. A nurse is preparing to administer an intermittent enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?

• A. Flush the tube with 30 mL of water after feeding
• B. Flush the tube with 10 mL of sterile water before feeding
• C. Place the client in a left lateral position
• D. Place the feeding bag 61 cm (24 in) above the client's abdomen

Correct answer: B

Rationale: Administering an intermittent enteral feeding through a gastrostomy tube requires flushing the tube with 10 mL of sterile water before feeding. This action helps ensure patency and prevents clogging. Choice A is incorrect because flushing after feeding does not address the need for pre-feeding tube flushing. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height of the feeding bag above the abdomen is typically regulated by healthcare facility policies and is not a universal standard.

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