Nursing Elites

1. Which intervention is most important for a client with chronic heart failure?

• A. Encourage fluid intake to prevent dehydration
• B. Monitor the client's weight daily to assess fluid balance
• C. Limit sodium intake to reduce fluid retention
• D. Restrict daily activity to prevent fatigue

Correct answer: B

Rationale: The correct answer is to monitor the client's weight daily to assess fluid balance in clients with chronic heart failure. Monitoring weight helps in detecting fluid retention or fluid loss, which is crucial in managing heart failure. Encouraging fluid intake to prevent dehydration (choice A) may worsen fluid overload in heart failure patients. Limiting sodium intake (choice C) is essential but not the most important intervention compared to monitoring weight. Restricting daily activity (choice D) is not recommended as it is important for clients with heart failure to engage in appropriate levels of physical activity to maintain their overall health.

2. A nurse is caring for a client receiving IV fluids. Which of the following should the nurse do upon noticing phlebitis at the IV site?

• A. Apply a cold compress to the site
• B. Notify the provider immediately
• C. Remove the IV catheter and restart it in another location
• D. Monitor the site for signs of infection

Correct answer: C

Rationale: Upon noticing phlebitis at the IV site, the nurse should remove the IV catheter and restart it in another location. Phlebitis is inflammation of the vein, and leaving the IV catheter in place can lead to further complications such as infection. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider immediately (Choice B) is important, but the immediate action to prevent complications is to remove the IV catheter. Monitoring the site for signs of infection (Choice D) is necessary, but the priority action is to remove and reinsert the IV catheter to prevent worsening of the phlebitis.

3. What are the differences between viral and bacterial infections?

• A. Viral infections often cause fatigue and body aches
• B. Bacterial infections often cause high fever and localized pain
• C. Viral infections are treated with antibiotics
• D. Bacterial infections are usually self-limiting

Correct answer: A

Rationale: Corrected Rationale: Viral infections often cause fatigue and body aches, while bacterial infections are more likely to cause high fever and localized pain. Choice A is the correct answer as it accurately reflects the symptoms commonly associated with viral infections. Bacterial infections, on the other hand, typically present with fever and localized pain, as stated in choice B. Choice C is incorrect as viral infections do not respond to antibiotics, while choice D is inaccurate because bacterial infections may require antibiotic treatment and are not always self-limiting.

4. A nurse is caring for a client who has heart failure and is receiving digoxin. Which of the following findings should the nurse identify as a sign of digoxin toxicity?

• A. Bradycardia
• B. Tachycardia
• C. Hypotension
• D. Increased appetite

Correct answer: A

Rationale: Corrected Rationale: Bradycardia is a common sign of digoxin toxicity. Digoxin, a medication used to treat heart failure, works by slowing down the heart rate and increasing the force of heart contractions. Excessive levels of digoxin can lead to toxicity, causing bradycardia (slow heart rate), among other symptoms. Tachycardia (fast heart rate) and hypotension (low blood pressure) are not typically associated with digoxin toxicity. Increased appetite is not a recognized sign of digoxin toxicity; instead, gastrointestinal symptoms like nausea, vomiting, and anorexia are more common.

5. A nurse is providing discharge instructions for a client using home oxygen. What is the most important safety measure?

• A. Store oxygen tanks in a closet when not in use
• B. Ensure that oxygen tanks are kept upright and away from heat sources
• C. Allow family members to smoke in designated areas
• D. Restrict fluid intake while using oxygen

Correct answer: B

Rationale: The correct answer is B: Ensure that oxygen tanks are kept upright and away from heat sources. This is the most important safety measure to prevent accidents related to home oxygen use. Storing oxygen tanks in a closet when not in use (choice A) is not recommended as they should be stored in a well-ventilated area. Allowing family members to smoke in designated areas (choice C) poses a significant fire hazard. Restricting fluid intake while using oxygen (choice D) is not a safety measure related to oxygen use.

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