Nursing Elites

1. A client with cirrhosis develops ascites. What is the nurse’s priority intervention?

• A. Administer diuretics as prescribed.
• B. Restrict fluid intake to manage fluid overload.
• C. Position the client in Fowler’s position and assess for respiratory distress.
• D. Measure the client's abdominal girth daily.

Correct answer: B

Rationale: The correct answer is B: Restrict fluid intake to manage fluid overload. In a client with cirrhosis developing ascites, the priority intervention is to restrict fluid intake. This helps manage fluid overload, prevent further complications, such as respiratory distress or kidney impairment, and reduce the accumulation of ascitic fluid. Administering diuretics may be a part of the treatment plan, but the primary focus should be on fluid restriction. Positioning the client in Fowler’s position and measuring the abdominal girth are important interventions but not the priority when managing ascites in cirrhosis.

2. A client with diabetes mellitus reports tingling in their feet. What is the nurse's best intervention?

• A. Advise the client to avoid wearing tight shoes.
• B. Refer the client to a podiatrist for foot care.
• C. Teach the client about blood sugar control and foot care.
• D. Administer insulin as prescribed.

Correct answer: C

Rationale: The correct intervention for a client with diabetes mellitus experiencing tingling in their feet is to teach the client about blood sugar control and foot care. This is essential because tingling in the feet can be a sign of neuropathy, a common complication of diabetes. Educating the client on maintaining proper blood sugar levels and foot care practices can help manage neuropathy symptoms and prevent complications like ulcers or infections. Advising the client to avoid tight shoes (Choice A) may help with comfort but does not address the underlying issue. Referring the client to a podiatrist (Choice B) is important for foot care but does not directly address blood sugar control. Administering insulin (Choice D) is not the priority for managing tingling in the feet related to neuropathy.

3. A client presents with three positive responses to the CAGE questionnaire. What interpretation should the nurse provide?

• A. CAGE is a tool for general substance abuse screening.
• B. Two positive responses suggest alcohol dependence.
• C. One positive response does not indicate alcohol addiction.
• D. All four responses must be positive to suggest alcohol dependence.

Correct answer: B

Rationale: Two positive responses on the CAGE questionnaire strongly suggest alcohol dependence. Choice A is incorrect as the CAGE questionnaire specifically targets alcohol abuse. Choice C is incorrect because one positive response is not enough to indicate alcohol addiction. Choice D is incorrect because alcohol dependence can be suggested with two positive responses, not all four.

4. After a lumbar puncture, a client reports a severe headache. What is the nurse's priority intervention?

• A. Administer a dose of acetaminophen.
• B. Elevate the head of the bed.
• C. Encourage the client to rest in a dark room.
• D. Administer caffeine to relieve the headache.

Correct answer: B

Rationale: After a lumbar puncture, a severe headache is often caused by cerebrospinal fluid leakage. Elevating the head of the bed or having the client lie flat can reduce cerebrospinal fluid pressure and alleviate the headache. These positions help prevent further fluid loss and relieve discomfort. While acetaminophen or caffeine may help in relieving the headache, changing the client's position is the priority to address the underlying cause. Resting in a dark room may be beneficial for headache relief but is not the priority intervention compared to adjusting the position to manage cerebrospinal fluid pressure.

5. A client with a history of adrenal insufficiency is admitted with acute adrenal crisis. The client complains of nausea and joint pain, vital signs show a temperature of 102°F, heart rate of 138, and blood pressure of 80/60. Which intervention should the nurse implement first?

• A. Obtain an analgesic prescription.
• B. Infuse an intravenous fluid bolus.
• C. Administer PRN oral antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: In acute adrenal crisis, the priority intervention is to infuse an intravenous fluid bolus to address the hypotension (blood pressure of 80/60) and help stabilize the client's condition. Adequate fluid volume is crucial in managing adrenal insufficiency crisis. Options A, C, and D do not directly address the hypotension and fluid volume depletion that are critical in this situation. Analgesics, antipyretics, and cooling blankets may be considered later, but the immediate focus should be on fluid resuscitation.

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