Nursing Elites

1. A client is admitted with a diagnosis of heart failure. Which dietary instruction should the nurse provide?

• A. Increase fluid intake to 3 liters per day.
• B. Limit sodium intake to 2 grams per day.
• C. Avoid foods high in potassium.
• D. Increase protein intake to promote healing.

Correct answer: B

Rationale: Limiting sodium intake to 2 grams per day (B) is a crucial dietary instruction for clients with heart failure. It helps manage fluid retention and reduces the workload on the heart. Excessive sodium can lead to fluid retention, worsening heart failure symptoms. Increasing fluid intake (A) can further exacerbate fluid overload in heart failure patients. Avoiding foods high in potassium (C) is not necessary unless the client has hyperkalemia; in heart failure, potassium restriction is not a primary dietary concern. Increasing protein intake (D) is not the priority for heart failure management; focusing on sodium restriction is more beneficial.

2. The client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?

• A. Observe the appearance of the skin under the ice pack.
• B. Instruct the client regarding the importance of the covering.
• C. Reapply the covering after filling it with fresh ice.
• D. Ask the client how long the ice pack was applied to the skin.

Correct answer: A

Rationale: The primary action for the nurse is to assess the skin under the ice pack to check for any potential thermal injury. This assessment is crucial to ensure the client's safety. Once the skin assessment is done and no harm is found, the nurse can proceed with other necessary actions such as providing instructions to the client or replacing the covering with fresh ice.

3. During the suctioning of a tracheostomy tube, if the catheter appears to attach to the tracheal walls and creates a pulling sensation, what is the best action for the nurse to take?

• A. Release the suction by opening the vent.
• B. Continue suctioning to remove obstruction.
• C. Increase the pressure.
• D. Suction deeper.

Correct answer: A

Rationale: When the catheter of the suctioning device attaches to the tracheal walls, causing a pulling sensation, the nurse should release the suction by opening the vent. This action will alleviate the pulling sensation and prevent trauma to the delicate tracheal walls. Continuing suctioning or applying more pressure can lead to tissue damage and should be avoided. Suctioning deeper can increase the risk of injuring the patient's airway.

4. How many drops per minute should a client weighing 182 pounds receive if a nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min? The drip factor is 60 gtt/ml.

• A. 31 gtt/min.
• B. 62 gtt/min.
• C. 93 gtt/min.
• D. 124 gtt/min.

Correct answer: D

Rationale: To determine the drops per minute for the client, first convert the client's weight from pounds to kilograms: 182/2.2 = 82.73 kg. Calculate the dosage by multiplying 5 mcg by the client's weight in kg: 5 mcg/kg/min × 82.73 kg = 413.65 mcg/min. Find the concentration of the solution in mcg/ml by dividing 250 ml by 50,000 mcg (50 mg): 250 ml/50,000 mcg = 200 mcg/ml. As the client needs 413.65 mcg/min and the solution is 200 mcg/ml, the client should receive 2.07 ml per minute. Finally, using the drip factor of 60 gtt/ml, multiply the ml per minute by the drip factor: 60 gtt/ml × 2.07 ml/min = 124.28 gtt/min, which rounds to 124 gtt/min. Therefore, the client should receive 124 drops per minute. Choice D is the correct answer. Choices A, B, and C are incorrect because they do not reflect the accurate calculation based on the client's weight, dosage, concentration of the solution, and drip factor.

5. The nursing staff in the cardiovascular intensive care unit is creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy?

• A. Remove identifying information of the clients who participated
• B. Recall that authored content may be legally discoverable
• C. Share material from credible, peer-reviewed sources only
• D. Respect all copyright laws when adding website content

Correct answer: A

Rationale: To protect client privacy on social media, it is essential to remove any identifying information of clients who participated in the project. This ensures that sensitive information is not disclosed without consent and maintains confidentiality. Choice B is incorrect because while authored content may be legally discoverable, it does not directly relate to protecting client privacy on social media. Choice C is incorrect as it pertains to the credibility of sources, not client privacy. Choice D is also incorrect as it focuses on copyright laws rather than client privacy protection.

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