Nursing Elites

1. A client with acute pancreatitis is receiving nothing by mouth (NPO) status. What is the nurse's priority intervention?

• A. Administer antiemetic medication as prescribed.
• B. Monitor the client's intake and output.
• C. Provide mouth care to keep the client comfortable.
• D. Elevate the client's head of the bed.

Correct answer: B

Rationale: The correct answer is B: Monitor the client's intake and output. When a client with acute pancreatitis is on NPO status, the nurse's priority intervention is to monitor the client's intake and output. This is crucial to assess for signs of dehydration, electrolyte imbalances, and to ensure the client is responding appropriately to treatment. Administering antiemetic medication (choice A) may be necessary for managing nausea and vomiting but is not the priority over monitoring intake and output. Providing mouth care (choice C) and elevating the client's head of the bed (choice D) are important aspects of care but do not take precedence over monitoring intake and output to prevent complications in clients with NPO status due to acute pancreatitis.

2. Which intervention should be included in the long-term plan of care for a client with COPD?

• A. Administer high-flow oxygen during sleep.
• B. Reduce risk factors for infection.
• C. Limit fluid intake to reduce secretions.
• D. Use diaphragmatic breathing to achieve better exhalation.

Correct answer: D

Rationale: The correct answer is D: 'Use diaphragmatic breathing to achieve better exhalation.' Diaphragmatic breathing is an essential intervention for clients with COPD as it helps improve exhalation and lung function, ultimately reducing symptoms over the long term. Option A is incorrect because high-flow oxygen during sleep is more relevant for clients with conditions like sleep apnea rather than COPD. Option B, 'Reduce risk factors for infection,' is important but not as specific to the long-term management of COPD as diaphragmatic breathing. Option C, 'Limit fluid intake to reduce secretions,' is not a recommended intervention for clients with COPD, as adequate hydration is crucial for maintaining respiratory health.

3. A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use?

• A. Use the Wong-Baker Faces pain rating scale
• B. Assess vital signs to gauge pain severity
• C. Ask the client to describe the pain
• D. Offer a 1-10 pain scale

Correct answer: C

Rationale: Asking the client to describe the pain is the most appropriate approach to assess the quality of pain. It provides valuable qualitative information that aids in understanding the nature, cause, and potential management strategies for the headache. While pain rating scales like the Wong-Baker Faces scale and using vital signs can help quantify pain severity, they do not offer specific descriptive details that can give insights into the type and characteristics of the pain experienced by the client.

4. A client receiving IV heparin reports tarry stools and abdominal pain. What interventions should the nurse implement?

• A. Prepare to administer warfarin.
• B. Assess the characteristics of the client's pain.
• C. Obtain recent partial thromboplastin time results.
• D. Monitor stool for the presence of blood.

Correct answer: D

Rationale: The correct intervention for the client receiving IV heparin who reports tarry stools and abdominal pain is to monitor the stool for the presence of blood. This is crucial to assess for gastrointestinal bleeding, a potential complication of heparin therapy. Assessing the characteristics of the client's pain may be helpful but is not the priority when signs of GI bleeding are present. Administering warfarin is not appropriate without a thorough assessment and confirmation of the cause of symptoms. While obtaining recent partial thromboplastin time results is important in monitoring heparin therapy, in this scenario, the immediate concern is to assess for possible GI bleeding.

5. A client with advanced chronic kidney disease (CKD) is scheduled for hemodialysis. Which dietary instruction should the nurse provide to the client?

• A. Limit fluid intake to prevent fluid overload
• B. Increase sodium intake to improve fluid balance
• C. Increase potassium intake to prevent hypokalemia
• D. Increase protein intake to promote healing

Correct answer: A

Rationale: The correct answer is A: 'Limit fluid intake to prevent fluid overload.' Clients with advanced chronic kidney disease are at risk of fluid retention, which can lead to complications like fluid overload and hypertension. Therefore, it is crucial to instruct the client to limit fluid intake. Choice B is incorrect because increasing sodium intake can exacerbate fluid retention and hypertension in clients with CKD. Choice C is incorrect as increasing potassium intake can be dangerous for clients with CKD who may already have elevated potassium levels. Choice D is incorrect because while protein intake may need to be adjusted for clients on hemodialysis, the priority in this case is managing fluid intake.

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