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 with a chest tube connected to a closed drainage system needs to be transported to the x-ray department. Which of the following actions should the nurse take?

• A. Clamp the chest tube prior to transferring the client to a wheelchair.
• B. Disconnect the chest tube from the drainage system during transport.
• C. Keep the drainage system below the level of the client's chest at all times.
• D. Empty the collection chamber prior to transport.

Correct answer: C

Rationale: When transporting a client with a chest tube connected to a closed drainage system, it is crucial to keep the drainage system below the level of the client's chest at all times. This positioning prevents the backflow of drainage into the client's chest, reducing the risk of complications. Clamping the chest tube, disconnecting it from the drainage system, or emptying the collection chamber are incorrect actions and can potentially harm the client or lead to complications.

3. A client with asthma has developed viral pharyngitis. Which of the following findings should the nurse expect?

• A. Petechiae on the chest and abdomen
• B. WBC 16,000/mm3
• C. Negative throat culture
• D. Severe hyperemia of pharyngeal mucosa

Correct answer: C

Rationale: Viral pharyngitis is typically caused by a virus, not bacteria, so a negative throat culture is an expected finding. The presence of petechiae on the chest and abdomen (Choice A) is not a common manifestation of viral pharyngitis. Elevated WBC count (Choice B) is more indicative of a bacterial infection rather than a viral one. Severe hyperemia of the pharyngeal mucosa (Choice D) is a possible finding in pharyngitis but is not specific to viral pharyngitis.

4. A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is much higher than previous readings & the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?

• A. Determining if the UAP knew how to take blood pressure
• B. Double-checking the UAP by taking another blood pressure
• C. Providing more appropriate supervision of the UAP
• D. Taking the blood pressure instead of delegating the task

Correct answer: C

Rationale: The most likely action by the nurse that would have prevented the negative outcome is providing more appropriate supervision of the UAP. Supervision is essential in delegation as it involves directing, evaluating, and following up on delegated tasks. By providing adequate supervision, the nurse can ensure that tasks are performed correctly and promptly identify any issues or abnormalities, such as a significant change in vital signs or the client's mental status. This proactive approach can help prevent adverse outcomes and enhance patient safety.

5. A client is receiving oxygen therapy via nasal cannula. Which finding indicates that the therapy is effective?

• A. The client is able to ambulate in the hall without dyspnea.
• B. The client has a respiratory rate of 24 breaths per minute.
• C. The client's oxygen saturation is 92%.
• D. The client has a productive cough.

Correct answer: A

Rationale: The correct answer is A. Effective oxygen therapy should improve the client's ability to perform activities without dyspnea. This indicates that the oxygen therapy is adequately supporting the client's respiratory needs. An oxygen saturation of 92% may suggest the need for a higher flow rate to improve oxygenation. A respiratory rate of 24 breaths per minute is elevated, indicating potential respiratory distress. A productive cough does not necessarily indicate effective oxygen therapy, as it is a symptom of respiratory irritation or infection, not oxygenation status.

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