Nursing Elites

1. A client with cirrhosis is experiencing ascites. Which dietary instruction should the nurse provide?

• A. Increase protein intake.
• B. Limit fluid intake to 1500 mL/day.
• C. Consume a low-sodium diet.
• D. Take a daily multivitamin.

Correct answer: C

Rationale: For a client with cirrhosis experiencing ascites, the nurse should instruct them to consume a low-sodium diet. This dietary modification helps reduce fluid retention and manage ascites by decreasing the amount of sodium in the body, which helps prevent fluid accumulation in the abdomen. Limiting sodium intake is crucial in managing ascites and preventing further complications in clients with cirrhosis.

2. A client who is receiving mechanical ventilation and has an ideal weight of 60 kg should have the tidal volume set at which of the following?

• A. 300 mL
• B. 480 mL
• C. 800 mL
• D. 950 mL

Correct answer: B

Rationale: Tidal volume is the amount of air delivered with each breath during mechanical ventilation. A common formula used to calculate tidal volume is 6-8 mL/kg of ideal body weight. For a client with an ideal weight of 60 kg, the expected tidal volume would be 60 kg x 6-8 mL/kg = 360-480 mL. Therefore, the most appropriate choice is 480 mL (Option B), which falls within the expected range based on the client's weight.

3. A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should not base her actions on which of the following information?

• A. The student should use his quick-relief inhaler.
• B. The student's asthma is not well controlled.
• C. The student's peak flow is 50% to 80% of his best peak flow.
• D. The student needs to go to the hospital

Correct answer: D

Rationale: In an asthma action plan, the yellow zone indicates caution and signals a need to monitor symptoms closely. When a student is in the yellow zone, the appropriate action is to follow the prescribed steps, which typically include using a quick-relief inhaler and closely monitoring peak flow. Going to the hospital is usually reserved for severe asthma exacerbations in the red zone. Therefore, the information that the student needs to go to the hospital is not typically appropriate when the student is in the yellow zone.

4. A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure?

• A. Do you have trouble breathing or chest pain?
• B. Are you able to walk upstairs without fatigue?
• C. Do you awake with breathlessness during the night?
• D. Do you have new-onset heaviness in your legs?

Correct answer: B

Rationale: Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night & peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure.

5. A client is being admitted to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority?

• A. Bowel sounds
• B. Surgical dressing
• C. Temperature
• D. Oxygen saturation

Correct answer: D

Rationale: The priority assessment for a client being admitted to the surgical unit following a cholecystectomy is oxygen saturation. Monitoring oxygen saturation is crucial to ensure adequate oxygenation and ventilation, especially after surgery. Hypoxia can have serious consequences and needs to be promptly addressed. While assessing bowel sounds, surgical dressing, and temperature are important, oxygen saturation takes precedence in this situation.

Similar Questions