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 client has developed phlebitis at the IV site. What should the nurse do immediately?

• A. Apply a warm compress over the IV site
• B. Discontinue the IV and notify the provider
• C. Monitor the site for signs of infection
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the immediate action the nurse should take is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and if left untreated, it can lead to serious complications such as infection, thrombosis, or sepsis. Removing the IV line helps prevent further irritation and infection. Applying a warm compress (Choice A) may provide some relief but does not address the root cause. Monitoring for signs of infection (Choice C) is important but not the immediate action needed to address phlebitis. Administering an anti-inflammatory medication (Choice D) may be prescribed by the provider but is not the first step in managing phlebitis.

3. A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider?

• A. Heart rate 80/min
• B. Heart rate 90/min
• C. Respiratory rate 28/min
• D. Heart rate 146/min

Correct answer: D

Rationale: A heart rate of 146/min is abnormal for a preschooler and indicates tachycardia, which should be reported to the provider. Choices A, B, and C fall within normal ranges for a preschooler's heart rate (80-120/min) and respiratory rate (22-34/min), so they do not require immediate reporting. Option D is the correct answer as it deviates significantly from the normal range and may indicate an underlying health issue that needs attention.

4. A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions should the nurse take?

• A. Wear a gown within 3 feet of the client
• B. Maintain a distance of 6 feet from the client
• C. Wear a surgical mask within 3 feet of the client
• D. Remove gloves before leaving the room

Correct answer: C

Rationale: The correct action for the nurse to take when maintaining droplet precautions for a client with meningitis is to wear a surgical mask within 3 feet of the client. This is essential to prevent the transmission of meningitis via respiratory droplets. Choice A is incorrect because wearing a gown is not specifically required for droplet precautions. Choice B suggests maintaining a distance of 6 feet, which is more applicable to airborne precautions, not droplet precautions. Choice D is incorrect as gloves should be removed and disposed of properly, but it is not related to droplet precautions specifically.

5. A client undergoing chemotherapy for cancer is being taught about potential adverse effects of the treatment. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will avoid drinking water before meals
• B. I might experience hair loss during treatment
• C. I might experience an increase in appetite
• D. I should expect my appetite to increase

Correct answer: B

Rationale: The correct answer is B because hair loss is a common adverse effect of chemotherapy. Options A, C, and D are incorrect. Avoiding drinking water before meals, experiencing an increase in appetite, or expecting appetite to increase are not related to the potential adverse effects of chemotherapy.

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