Nursing Elites

1. When a client with dementia frequently becomes agitated, what should the nurse prioritize investigating?

• A. Fluid and electrolyte imbalances
• B. Medication history
• C. Environmental factors
• D. Cognitive functioning

Correct answer: B

Rationale: The correct answer is to prioritize investigating the client's medication history. This is important because certain medications can contribute to agitation in clients with dementia. Understanding the medication history can help identify potential causes of agitation and guide appropriate interventions. Checking for fluid and electrolyte imbalances is important in healthcare but may not directly relate to the client's agitation. While environmental factors can influence behavior, investigating the medication history is more pertinent in this case. Cognitive functioning assessment is crucial in dementia care but may not be the priority when addressing acute agitation.

2. Which of the following interventions is most appropriate for a client with a pressure ulcer who has a low albumin level?

• A. Increase protein intake to improve healing
• B. Consult with a dietitian to create a high-protein diet
• C. Provide nutritional supplements
• D. Increase IV fluid intake to improve hydration

Correct answer: B

Rationale: Consulting with a dietitian to create a high-protein diet is the most appropriate intervention for a client with a pressure ulcer and low albumin level. This intervention can help address the client's poor nutritional status, support wound healing, and specifically target the low albumin level. Increasing protein intake alone (Choice A) may not be sufficient without proper guidance. Providing nutritional supplements (Choice C) can be beneficial but consulting with a dietitian for a personalized plan is more effective in this case. Increasing IV fluid intake (Choice D) primarily targets hydration and may not directly address the underlying issue of low albumin and poor nutritional status.

3. A nurse is reinforcing teaching to a client with hypertension. What lifestyle change should be emphasized?

• A. Increase intake of sodium-rich foods
• B. Limit intake of high-fat foods
• C. Reduce intake of caffeinated beverages
• D. Eat high-protein foods to lower blood pressure

Correct answer: B

Rationale: The correct lifestyle change that should be emphasized for a client with hypertension is to limit the intake of high-fat foods. High-fat foods can contribute to high blood pressure, so reducing their consumption is important in managing hypertension. Choice A is incorrect because increasing intake of sodium-rich foods can worsen hypertension due to their effect on blood pressure. Choice C is incorrect as caffeinated beverages can also elevate blood pressure. Choice D is incorrect because while high-protein foods can be beneficial, they do not directly lower blood pressure like reducing high-fat foods would.

4. A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

• A. Hemoglobin A1c of 6%
• B. Fasting blood glucose of 90 mg/dL
• C. Blood glucose of 200 mg/dL
• D. Blood glucose of 100 mg/dL

Correct answer: C

Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia and should be reported for potential insulin adjustment.

5. What is the most appropriate response when a client with chronic kidney disease asks about fluid restrictions?

• A. Fluid restrictions are not needed for all clients with chronic kidney disease.
• B. You may need to limit fluid intake to prevent fluid overload.
• C. Fluid restrictions are based on your lab results and daily weights.
• D. Restricting fluids is only necessary during dialysis.

Correct answer: B

Rationale: The most appropriate response when a client with chronic kidney disease asks about fluid restrictions is to inform them that limiting fluid intake may be necessary to prevent fluid overload. This is crucial in managing the condition and preventing complications such as edema and electrolyte imbalances. Choice A is incorrect as fluid restrictions are commonly advised for clients with chronic kidney disease. Choice C is partially correct as fluid restrictions are indeed based on lab results and daily weights, but the primary goal is to prevent fluid overload. Choice D is incorrect because fluid restrictions are not limited to just during dialysis; they are often recommended throughout the day to manage the condition.

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