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 caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?

• A. Cancer of any type
• B. Impaired hearing
• C. Prescription drug intoxication
• D. Heart failure

Correct answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium in older adults is commonly caused by medication side effects or interactions. Investigating prescription drug intoxication is crucial as it can be a reversible cause of delirium. While cancer, impaired hearing, and heart failure are important considerations in overall care, prescription drug intoxication takes precedence in cases of delirium.

3. What are the differences between Type 1 and Type 2 diabetes in terms of treatment?

• A. Type 1: Insulin therapy; Type 2: Lifestyle modifications and oral agents
• B. Type 1: Oral agents; Type 2: Insulin therapy
• C. Type 1: Insulin resistance; Type 2: Insulin deficiency
• D. Type 1: Exercise and diet; Type 2: Insulin only

Correct answer: A

Rationale: The correct answer is A because Type 1 diabetes necessitates insulin therapy, whereas Type 2 diabetes is managed with lifestyle modifications and oral agents. Choice B is incorrect because Type 1 diabetes does not use oral agents as a primary treatment. Choice C is incorrect as it describes the pathophysiology of diabetes types rather than their treatments. Choice D is incorrect because Type 2 diabetes management involves more than just insulin and includes lifestyle changes and oral medications.

4. A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?

• A. Apply oxygen at 10 L/min via face mask
• B. Position the client on their side
• C. Call for a Cesarean delivery
• D. Administer oxytocin

Correct answer: B

Rationale: Late decelerations indicate uteroplacental insufficiency, and the priority nursing action is to improve placental perfusion. Positioning the client on their side, particularly the left side, can enhance blood flow to the placenta and fetus by reducing pressure on the vena cava and increasing cardiac output. Applying oxygen, although helpful, is not the initial priority in this situation. Calling for a Cesarean delivery is not warranted unless other interventions fail to correct the late decelerations. Administering oxytocin can worsen the condition by increasing uterine contractions, exacerbating fetal distress.

5. Which instruction should be emphasized for a client with diabetes being discharged?

• A. Check blood sugar once daily
• B. Take insulin before meals as prescribed
• C. Monitor glucose levels weekly
• D. Eat carbohydrate-rich meals to maintain glucose levels

Correct answer: B

Rationale: The correct answer is to 'Take insulin before meals as prescribed' because it is crucial for managing blood glucose levels effectively in clients with diabetes. Insulin helps the body utilize glucose from the food consumed, preventing high blood sugar levels. Checking blood sugar once daily (Choice A) may not be sufficient for proper management, as blood sugar levels can fluctuate throughout the day. Monitoring glucose levels weekly (Choice C) is too infrequent and may lead to missed opportunities for timely intervention. Eating carbohydrate-rich meals to maintain glucose levels (Choice D) is not appropriate advice, as it can cause rapid spikes in blood sugar levels, especially without the proper insulin dosage.

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