Nursing Elites

1. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client’s fluid status?

• A. Measuring and recording fluid intake and output
• B. Weighing the client daily at the same time each day
• C. Assessing the client’s vital signs every 4 hours
• D. Checking the client’s lungs for crackles during every shift

Correct answer: B

Rationale: The correct answer is B. Weighing the client daily at the same time each day is the most accurate method for monitoring fluid balance. Changes in body weight can indicate fluid retention or loss. Measuring and recording fluid intake and output (choice A) is important but may not reflect total body fluid status accurately. Assessing vital signs (choice C) and checking the client's lungs for crackles (choice D) are important assessments but do not directly provide the most accurate monitoring of fluid status.

2. In assessing the client's chest, which position best shows chest expansion as well as its movements?

• A. Sitting
• B. Prone
• C. Sidelying
• D. Supine

Correct answer: A

Rationale: The correct answer is A: Sitting. When the client is seated, their chest is in an optimal position for observing the full range of chest expansion during breathing. This position allows for easy visualization of chest movements and expansion as the client breathes in and out, providing a comprehensive assessment of respiratory function. Choice B, Prone, is incorrect as lying face down would not provide a clear view of chest expansion. Choice C, Sidelying, is also incorrect as this position may limit the visibility of chest movements. Choice D, Supine, is not the best position for assessing chest expansion as it may not offer a clear observation of chest movements during breathing.

3. In managing cystic fibrosis, which nutrition therapy is crucial for patients with pancreatic insufficiency?

• A. A low-fat diet to prevent steatorrhea
• B. A low-sodium diet to normalize fluid status
• C. A high-fiber diet to normalize bowel function
• D. Pancreatic enzyme replacement therapy to help digestion

Correct answer: D

Rationale: In cystic fibrosis patients with pancreatic insufficiency, pancreatic enzyme replacement therapy is vital for aiding digestion. This therapy helps compensate for the decreased production of digestive enzymes by the pancreas, enabling the proper breakdown and absorption of nutrients. Options A, B, and C are not the primary focus of nutrition therapy for cystic fibrosis patients with pancreatic insufficiency.

4. Which of the following is inappropriate in collecting midstream clean-catch urine specimen for urine analysis?

• A. Collect early in the morning, first voided specimen
• B. Do perineal care before specimen collection
• C. Collect 5 to 10 ml of urine
• D. Discard the first flow of urine

Correct answer: C

Rationale: The inappropriate action in collecting a midstream clean-catch urine specimen for urine analysis is to collect only 5 to 10 ml of urine. Adequate urine volume of 30 to 60 ml is required for accurate testing. Collecting a small amount like 5 to 10 ml may lead to inaccurate results due to insufficient sample size. It is crucial to follow proper collection techniques, such as discarding the first flow of urine, performing perineal care, and collecting an adequate volume, to ensure reliable test results.

5. The nurse has given post-procedure instructions to a client who underwent a colonoscopy. Evaluation of learning would be evident if the client makes which statement(s)?

• A. All of the above
• B. “My abdominal muscles may be tender because of the procedure.”
• C. “My diet should be light at first, and then I can progress to a regular diet.”
• D. “It is normal to feel gassy or bloated for a short while after the procedure.”

Correct answer: A

Rationale: The correct answer is A: "All of the above." Evaluation of learning after a colonoscopy would be evident if the client mentions all the statements provided. Mild tenderness in the abdominal muscles, starting with a light diet and progressing to a regular diet, and experiencing gas or bloating temporarily are all expected after a colonoscopy. Therefore, all the statements are correct in demonstrating the client's understanding of the post-procedure instructions. Choices B, C, and D provide accurate information about the expected outcomes following a colonoscopy, making them incorrect answers individually but correct when combined as option A.

Similar Questions