Nursing Elites

1. A client with cirrhosis is experiencing ascites and peripheral edema. What is the nurse's priority intervention?

• A. Administer furosemide as prescribed.
• B. Administer albumin to increase oncotic pressure.
• C. Elevate the client's legs to reduce swelling.
• D. Administer a sodium-restricted diet.

Correct answer: A

Rationale: The correct answer is A: Administer furosemide as prescribed. Administering furosemide, a loop diuretic, is the priority intervention in a client with cirrhosis experiencing ascites and peripheral edema. Furosemide helps promote diuresis and reduce fluid buildup in the body. Choice B, administering albumin to increase oncotic pressure, may be beneficial in some cases but is not the priority intervention for immediate fluid removal. Elevating the client's legs (Choice C) and administering a sodium-restricted diet (Choice D) are important aspects of managing edema and ascites but are not the priority interventions in this situation.

2. A client is newly diagnosed with a duodenal ulcer. What information should the nurse provide during medication teaching?

• A. Take antacids regularly to manage symptoms.
• B. Avoid spicy foods and alcohol.
• C. Ensure proper administration of antibiotics.
• D. Stop all food intake until symptoms subside.

Correct answer: B

Rationale: The correct answer is B. Clients with duodenal ulcers should avoid spicy foods and alcohol as they can exacerbate symptoms and delay healing. Choice A is incorrect because while antacids may help with symptoms, they are not the primary focus of medication teaching for duodenal ulcers. Choice C is not directly related to medication teaching for duodenal ulcers unless antibiotics are specifically prescribed. Choice D is incorrect as stopping all food intake is not recommended and can lead to other complications.

3. The nurse is providing education to a client who experiences recurrent levels of moderate anxiety in response to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

• A. Practice using muscle relaxation techniques
• B. Take medication only when anxiety is at its worst
• C. Avoid interactions that trigger stress
• D. Engage in exercise during anxious periods

Correct answer: A

Rationale: Teaching relaxation techniques, such as muscle relaxation, helps the client manage anxiety more effectively. These techniques can be practiced regularly to reduce overall anxiety and can complement prescribed medications. Choice B is incorrect because medication should be taken as prescribed, not only when anxiety is at its worst. Choice C is incorrect as avoiding interactions that trigger stress may not always be feasible and does not teach the client coping mechanisms. Choice D is incorrect as engaging in exercise during anxious periods may not be the most effective strategy for managing moderate anxiety levels.

4. A client has burns covering 40% of their total body surface area (TBSA). What is the nurse’s priority action?

• A. Monitor the client's urinary output hourly.
• B. Apply cool, moist dressings to the burned areas.
• C. Administer pain medication to reduce discomfort.
• D. Administer IV fluids to prevent hypovolemia.

Correct answer: A

Rationale: The correct answer is A: Monitor the client's urinary output hourly. Clients with burns covering a large percentage of their total body surface area are at high risk for hypovolemia due to fluid loss. Monitoring urinary output is crucial because it helps assess kidney function and fluid balance, providing essential information about the client's hemodynamic status. Applying cool, moist dressings (choice B) is important but not the priority over assessing fluid balance. Administering pain medication (choice C) is essential for comfort but not the priority over monitoring for potential complications like hypovolemia. Administering IV fluids (choice D) is important to prevent hypovolemia, but monitoring urinary output should be the priority to guide fluid resuscitation.

5. The nurse identifies an electrolyte imbalance, a weight gain of 4.4 lbs in 24 hours, and an elevated central venous pressure for a client with full-thickness burns. Which intervention should the nurse implement?

• A. Administer diuretics
• B. Review urine output
• C. Auscultate for irregular heart rate
• D. Increase oral fluid intake

Correct answer: C

Rationale: An elevated CVP and sudden weight gain indicate fluid overload, which can strain the heart. Auscultating for an irregular heart rate is crucial as electrolyte imbalances and fluid shifts after burns can lead to cardiac complications. Monitoring the heart rate is a priority to detect any cardiac distress early. While reviewing urine output and administering diuretics are important interventions, they should come after ensuring the client's cardiac status is stable. Increasing oral fluid intake may exacerbate the fluid overload, making it an inappropriate intervention in this scenario.

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