Nursing Elites

1. A client with cirrhosis of the liver is experiencing ascites. The nurse should implement which of the following interventions?

• A. Restrict fluid intake
• B. Increase sodium intake
• C. Encourage high-protein diet
• D. Administer diuretics

Correct answer: D

Rationale: Corrected Rationale: Ascites, the accumulation of fluid in the abdominal cavity, is a common complication of cirrhosis. Diuretics are the primary intervention to manage ascites by promoting the excretion of excess fluid from the body, thus reducing abdominal swelling. Restricting fluid intake (Choice A) would not be appropriate as it may lead to dehydration. Increasing sodium intake (Choice B) is contraindicated as it can worsen fluid retention. Encouraging a high-protein diet (Choice C) is not directly related to managing ascites.

2. What is the FIRST STEP for thermal protection of a newborn?

• A. Drying the baby thoroughly immediately after birth
• B. Covering the baby with a clean, dry cloth after the cord has been cut
• C. Drying the baby thoroughly after the cord has been cut
• D. Covering the baby with a clean, dry cloth immediately after birth

Correct answer: A

Rationale: The correct first step for thermal protection of a newborn is to dry the baby thoroughly immediately after birth. This helps prevent heat loss and is crucial in maintaining the baby's body temperature. Choice B, covering the baby with a clean, dry cloth after the cord has been cut, is not the initial step as drying the baby comes first. Choice C, drying the baby thoroughly after the cord has been cut, is also not the first step. Choice D, covering the baby with a clean, dry cloth immediately after birth, is not as effective as drying the baby to prevent heat loss.

3. The client with asthma who is sensitive to house dust-mites is being instructed by the nurse. Which information about prevention of asthma episodes would be the most helpful to include during the teaching?

• A. Change the pillow covers every month
• B. Wash bed linens in warm water with a cold rinse
• C. Wash and rinse the bed linens in hot water
• D. Use air filters in the furnace system

Correct answer: C

Rationale: The correct answer is to wash and rinse the bed linens in hot water to help eliminate dust mites, a common trigger for asthma episodes. Washing in hot water is more effective in killing dust mites compared to warm water. Changing pillow covers every month may help but is not as effective as washing bed linens in hot water. Using air filters in the furnace system may improve air quality but does not directly target dust mites on bed linens.

4. During the beginning shift assessment of a client with asthma who is receiving oxygen via nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding?

• A. Pulse oximetry reading of 89%
• B. Crackles at the base of the lungs on auscultation
• C. Rapid shallow respirations with intermittent wheezes
• D. Excessive thirst with a dry cracked tongue

Correct answer: C

Rationale: Rapid, shallow respirations with intermittent wheezes are concerning as they indicate a potential worsening of the client's asthma. This finding suggests airway narrowing, which can lead to respiratory failure. Immediate intervention is required to address this respiratory distress. A pulse oximetry reading of 89% is low and indicates hypoxemia, but the respiratory pattern described in option C takes priority as it directly reflects the client's respiratory status. Crackles at the base of the lungs suggest fluid accumulation, which is important but not as immediately critical as the respiratory distress in asthma. Excessive thirst and a dry cracked tongue may indicate dehydration, which is relevant but not as urgent as the respiratory compromise presented in option C.

5. During a home visit for a family with a new baby, what should the nurse assess first?

• A. feeding patterns
• B. sleeping arrangements
• C. support system
• D. immunization status

Correct answer: A

Rationale: Assessing feeding patterns is the priority during a home visit for a family with a new baby because it is crucial for the health and growth of the newborn. By evaluating the feeding patterns, the nurse can ensure that the baby is receiving adequate nutrition and address any feeding issues promptly. While sleeping arrangements, support system, and immunization status are important aspects to assess during a home visit, they are not as critical as ensuring the newborn's nutritional needs are being met.

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