Nursing Elites

1. A client with cirrhosis and ascites asks about fluid restriction. What is the nurse’s best response?

• A. Increase the client's fluid intake gradually.
• B. Restrict oral fluids to 1500 ml per day.
• C. Explain the importance of following a low-sodium diet.
• D. Increase dietary protein to reduce fluid retention.

Correct answer: B

Rationale: The correct answer is B: 'Restrict oral fluids to 1500 ml per day.' In clients with cirrhosis and ascites, fluid restriction is essential to prevent fluid overload, which can worsen symptoms of liver failure. Option A is incorrect because increasing fluid intake would exacerbate the issue of fluid overload. Option C, while important, is not the best initial response to the client's question about fluid restriction. Option D is incorrect as increasing dietary protein does not directly address fluid restriction in clients with cirrhosis and ascites.

2. After receiving hemodialysis, what is the nurse's priority assessment for a client with chronic kidney disease?

• A. Monitor the client's potassium level.
• B. Assess the client's blood pressure.
• C. Check the client's hemoglobin and hematocrit levels.
• D. Monitor for signs of infection.

Correct answer: A

Rationale: The correct answer is to monitor the client's potassium level. During hemodialysis, there is a risk of potassium shifting, which can lead to life-threatening arrhythmias if not properly managed. Assessing the potassium level is crucial to prevent complications. While assessing blood pressure, checking hemoglobin and hematocrit levels, and monitoring for signs of infection are important aspects of care for a client with chronic kidney disease, monitoring potassium levels takes precedence due to its immediate life-threatening potential post-dialysis.

3. The healthcare provider is assessing a client who has just received anesthesia. What is the most critical finding to report to the healthcare provider?

• A. Client reports dizziness
• B. Client has a drop in blood pressure
• C. Client experiences mild nausea
• D. Client reports dry mouth

Correct answer: B

Rationale: A significant drop in blood pressure following anesthesia could indicate a serious reaction, such as hypovolemia or anesthetic-induced hypotension. This requires immediate medical attention, while other symptoms like dizziness, mild nausea, and dry mouth are more common and less critical. Dizziness could be expected due to the effects of anesthesia, mild nausea is a common side effect, and dry mouth is a known effect of anesthesia as well.

4. A client with chronic liver disease develops jaundice. What is the most important assessment the nurse should perform?

• A. Assess the client’s skin for lesions or sores.
• B. Monitor the client’s liver function tests.
• C. Assess for changes in mental status and behavior.
• D. Monitor the client’s urine output closely.

Correct answer: D

Rationale: In a client with chronic liver disease developing jaundice, the most important assessment the nurse should perform is to monitor the client’s urine output closely. Jaundice can indicate worsening liver function, so monitoring urine output helps assess kidney function and fluid balance, which are critical in chronic liver disease. Assessing the client’s skin for lesions or sores (Choice A) may be relevant for dermatological conditions but is not the priority in this case. Monitoring liver function tests (Choice B) is important but may not provide immediate information on the client’s current status. Assessing for changes in mental status and behavior (Choice C) is important for detecting hepatic encephalopathy but does not directly address the immediate concern of fluid balance and kidney function in the presence of jaundice.

5. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

• A. Allow the client to melt ice chips in the mouth
• B. Provide mints to freshen the breath
• C. Perform frequent oral care with a tooth sponge
• D. Swab the mouth with glycerin swabs

Correct answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this scenario. This helps maintain comfort and prevent dryness in clients with nasogastric tubes. Allowing the client to melt ice chips in the mouth may not address oral care needs effectively. Providing mints to freshen the breath is not the priority when the client needs oral care. Swabbing the mouth with glycerin swabs may not be as effective as performing thorough oral care with a tooth sponge.

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