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 male client with HIV on saquinavir and other antiretrovirals reports increased hunger and thirst but weight loss. Which action should the nurse take?

• A. Use a glucometer to assess capillary glucose.
• B. Explain to the client that an increased dose of medication is needed.
• C. Reassure the client that weight will improve as viral load decreases.
• D. Teach the client how to measure his weight accurately.

Correct answer: A

Rationale: Increased thirst and hunger while losing weight may indicate hyperglycemia, a common side effect of saquinavir and other antiretrovirals. Using a glucometer to assess capillary glucose levels is essential to evaluate for hyperglycemia. Choice B is incorrect because increasing the dose of medication without assessing blood glucose levels can be dangerous. Choice C is incorrect because weight loss may not necessarily improve with viral load reduction and doesn't address the immediate concern of hyperglycemia. Choice D is irrelevant to the presenting symptoms and should not be a priority over assessing for hyperglycemia.

3. A client is experiencing acute bronchospasm. What is the nurse's priority intervention?

• A. Administer a nebulizer treatment of albuterol.
• B. Start an IV infusion of normal saline.
• C. Administer oxygen at 4L/min via nasal cannula.
• D. Position the client in a high Fowler's position.

Correct answer: A

Rationale: The correct answer is to administer a nebulizer treatment of albuterol. In acute bronchospasm, the priority intervention is to deliver a bronchodilator like albuterol to open the airways and improve breathing. Starting an IV infusion of normal saline (Choice B) may be necessary but not the priority in this situation. Administering oxygen at 4L/min via nasal cannula (Choice C) is important but not the first intervention for bronchospasm. Positioning the client in a high Fowler's position (Choice D) can help with breathing but is not the priority over administering a bronchodilator.

4. The nurse is providing discharge teaching to a client with gastroesophageal reflux disease (GERD). Which instruction should the nurse include in the teaching?

• A. Increase fluid intake with meals
• B. Avoid lying down for at least 30 minutes after eating
• C. Eat small, frequent meals throughout the day
• D. Consume spicy foods in moderation

Correct answer: C

Rationale: The correct instruction for the nurse to include in the teaching for a client with GERD is to eat small, frequent meals throughout the day. This recommendation helps reduce symptoms by preventing the stomach from becoming overly full, which can increase pressure on the lower esophageal sphincter and lead to acid reflux. Choices A, B, and D are incorrect because increasing fluid intake with meals can exacerbate GERD symptoms, lying down after eating can worsen reflux, and consuming spicy foods can trigger acid reflux in individuals with GERD.

5. The nurse is preparing to administer a blood transfusion to a client. Which action is most important for the nurse to take before starting the transfusion?

• A. Administer pre-transfusion medication
• B. Ensure the client has an adequate fluid intake
• C. Monitor the client's vital signs
• D. Verify the blood type with another nurse

Correct answer: D

Rationale: Verifying the blood type with another nurse is critical before starting a blood transfusion to prevent a potentially life-threatening transfusion reaction. This step ensures that the client receives the correct blood product. Administering pre-transfusion medication, ensuring adequate fluid intake, and monitoring vital signs are important steps during the transfusion process, but verifying the blood type is the most crucial step to ensure patient safety.

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