Nursing Elites

1. Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?

• A. Explain the experience of having delirium
• B. Resume a normal sleep-wake cycle
• C. Regain orientation to time and place
• D. Establish normal bowel and bladder function

Correct answer: C

Rationale: Regaining orientation to time and place is a realistic short-term goal for clients with delirium. It helps the individual become aware of their surroundings and current situation, aiding in reducing confusion and disorientation. Choice A is incorrect because the goal is focused on the client's understanding, not on explaining the experience of delirium. Choice B, resuming a normal sleep-wake cycle, may take longer than 2 to 3 days to achieve and is not directly related to regaining orientation. Choice D, establishing normal bowel and bladder function, is important but may not be a short-term goal specifically related to delirium.

2. How should a healthcare professional assess a patient for potential deep vein thrombosis (DVT)?

• A. Assess for unilateral leg swelling
• B. Encourage early mobilization
• C. Check for calf tenderness
• D. Observe for redness and warmth

Correct answer: A

Rationale: To assess a patient for potential deep vein thrombosis (DVT), healthcare professionals should look for unilateral leg swelling. This is a classic sign of DVT. While encouraging early mobilization is generally beneficial for preventing DVT, it is not a method of assessment. Checking for calf tenderness is also relevant but not as specific as unilateral leg swelling. Observing for redness and warmth can be signs of inflammation but are not as specific to DVT as unilateral leg swelling.

3. What is the priority nursing action for a dehydrated client who needs fluids?

• A. Administer antiemetics to prevent vomiting
• B. Monitor electrolyte levels frequently
• C. Administer oral rehydration solutions
• D. Insert an NG tube for fluid administration

Correct answer: B

Rationale: The correct answer is to monitor electrolyte levels frequently. When a client is dehydrated and needs fluids, it is essential to monitor electrolyte levels to prevent complications such as electrolyte imbalances. Administering antiemetics to prevent vomiting (Choice A) may be necessary but is not the priority when addressing dehydration. Administering oral rehydration solutions (Choice C) can be beneficial, but monitoring electrolyte levels takes precedence to ensure proper hydration. Inserting an NG tube for fluid administration (Choice D) is invasive and not typically the first-line approach for managing dehydration.

4. A nurse is caring for a client who is experiencing chronic pain. Which of the following interventions should the nurse implement?

• A. Provide the client with distractions such as television
• B. Administer pain medication around the clock
• C. Teach the client relaxation techniques
• D. Perform massage therapy on the client

Correct answer: C

Rationale: The correct intervention for a client experiencing chronic pain is to teach relaxation techniques, as it helps in managing pain more effectively by reducing stress and anxiety. Distractions like television (Choice A) may offer temporary relief but do not address the root cause of chronic pain. Administering pain medication around the clock (Choice B) may lead to dependency and not promote long-term pain management. While massage therapy (Choice D) can be beneficial, teaching relaxation techniques (Choice C) is more directly focused on empowering the client to manage their pain independently.

5. A client who is newly diagnosed with iron deficiency anemia needs to include foods rich in iron in their diet. Which of the following foods should the nurse recommend as having the highest amount of iron?

• A. Boiled spinach
• B. Raw carrots
• C. Boiled chicken
• D. Yogurt

Correct answer: A

Rationale: Boiled spinach is an excellent source of iron, making it a top choice for individuals with iron deficiency anemia. Spinach contains non-heme iron, which may not be absorbed as efficiently as heme iron from animal sources but is still beneficial. Raw carrots, boiled chicken, and yogurt are not as rich in iron compared to spinach. Carrots are more known for their beta-carotene content, chicken is a good source of protein but not high in iron, and yogurt does not contain significant amounts of iron.

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