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. When a client with dementia frequently becomes agitated, what should the nurse prioritize investigating?

• A. Fluid and electrolyte imbalances
• B. Medication history
• C. Environmental factors
• D. Cognitive functioning

Correct answer: B

Rationale: The correct answer is to prioritize investigating the client's medication history. This is important because certain medications can contribute to agitation in clients with dementia. Understanding the medication history can help identify potential causes of agitation and guide appropriate interventions. Checking for fluid and electrolyte imbalances is important in healthcare but may not directly relate to the client's agitation. While environmental factors can influence behavior, investigating the medication history is more pertinent in this case. Cognitive functioning assessment is crucial in dementia care but may not be the priority when addressing acute agitation.

3. A client has undergone a bronchoscopy, and a nurse is providing care post-procedure. What should the nurse do first?

• A. Monitor the client's oxygen levels
• B. Encourage the client to eat
• C. Check for a gag reflex
• D. Administer IV fluids

Correct answer: C

Rationale: After a bronchoscopy, the nurse's priority is to check for a gag reflex. This action helps assess the client's ability to protect their airway after sedation. Maintaining airway patency is crucial post-procedure. Monitoring oxygen levels is important but ensuring airway protection takes precedence. Encouraging the client to eat and administering IV fluids are essential aspects of care but are not the immediate priority in this situation.

4. A client with peripheral arterial disease (PAD) is being taught about foot care by a nurse. Which of the following instructions should the nurse include?

• A. Apply lotion between the toes
• B. Wear shoes that fit properly
• C. Walk barefoot at home
• D. Apply ice to the feet daily

Correct answer: B

Rationale: The correct answer is B: 'Wear shoes that fit properly.' In peripheral arterial disease (PAD), it is crucial to wear shoes that fit well to prevent foot injuries. Choice A is incorrect because applying lotion between the toes can increase the risk of infection. Choice C is incorrect since walking barefoot at home can lead to injuries, especially in individuals with PAD. Choice D is incorrect as applying ice to the feet daily can further reduce blood flow to the extremities, worsening the condition in PAD.

5. What are the complications of diabetic ketoacidosis?

• A. Electrolyte imbalance and dehydration
• B. Hypoglycemia and increased urination
• C. Kidney failure and respiratory distress
• D. Liver failure and hypertension

Correct answer: A

Rationale: The correct answer is A: Electrolyte imbalance and dehydration. Diabetic ketoacidosis can lead to imbalances in electrolytes such as potassium, sodium, and chloride, as well as dehydration due to excess urination and vomiting. These complications should be managed promptly with appropriate fluids and insulin. Choices B, C, and D are incorrect. Hypoglycemia and increased urination are not typical complications of diabetic ketoacidosis; kidney failure and respiratory distress may occur in severe cases but are not the primary complications. Liver failure and hypertension are not directly associated with diabetic ketoacidosis.

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