Nursing Elites

1. While assessing a client with fluid volume deficit, which of the following findings should the nurse expect?

• A. Bradycardia
• B. Increased skin turgor
• C. Dry mucous membranes
• D. Hypertension

Correct answer: C

Rationale: Dry mucous membranes are a classic clinical manifestation of fluid volume deficit. Dehydration leads to reduced fluid intake or excessive fluid loss, resulting in decreased moisture in the mucous membranes. Bradycardia, increased skin turgor, and hypertension are not typically associated with fluid volume deficit. Bradycardia is more commonly seen in conditions like hypothyroidism or increased intracranial pressure. Increased skin turgor is a sign of dehydration, not deficit. Hypertension is not a typical finding in fluid volume deficit.

2. A client with pancreatitis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should increase my intake of high-fat foods.
• B. I should decrease my intake of high-fat foods.
• C. I should increase my intake of high-protein foods.
• D. I should decrease my intake of high-protein foods.

Correct answer: B

Rationale: The correct answer is B. Decreasing the intake of high-fat foods is essential in managing pancreatitis as high-fat foods can exacerbate symptoms and lead to complications. By reducing high-fat foods in their diet, the client demonstrates an understanding of the dietary management needed for pancreatitis. Choices A, C, and D are incorrect. Increasing high-fat foods (Choice A) is not recommended for pancreatitis as it can worsen the condition. While high-protein foods (Choice C) can be beneficial in some cases, the primary focus in pancreatitis management is on reducing fat intake. Decreasing high-protein foods (Choice D) is not a key dietary management approach for pancreatitis.

3. When teaching a client with a new diagnosis of heart failure about dietary management, which of the following statements should the nurse include?

• A. Increase your intake of sodium-rich foods.
• B. Decrease your intake of sodium-rich foods.
• C. Avoid foods that contain lactose.
• D. Increase your intake of dairy products.

Correct answer: B

Rationale: The correct answer is to decrease the intake of sodium-rich foods. Sodium restriction is crucial in managing heart failure as it helps to reduce fluid retention and alleviate symptoms. Excessive sodium intake can lead to fluid buildup in the body, worsening heart failure. Therefore, advising the client to decrease sodium-rich foods is essential for their overall health and management of the condition. Choices A, C, and D are incorrect. Increasing intake of sodium-rich foods (Choice A) would worsen fluid retention and heart failure symptoms. Avoiding foods that contain lactose (Choice C) is not directly related to heart failure management through sodium restriction. Increasing intake of dairy products (Choice D) may not be suitable for all heart failure patients, especially if they need to limit saturated fats or cholesterol in their diet.

4. When teaching a client with a new diagnosis of hypertension about medication adherence, which statement should the nurse include?

• A. You can stop taking your medication once your blood pressure is normal.
• B. You should take your medication at the same time every day.
• C. You can double your dose if you miss a dose.
• D. You should take your medication with a high-fat meal.

Correct answer: B

Rationale: The correct answer is B: 'You should take your medication at the same time every day.' Taking medication consistently at the same time daily is crucial for maintaining steady blood levels and effectively managing hypertension. It helps ensure that the medication works optimally and provides the best control of blood pressure throughout the day. Choice A is incorrect because stopping medication once blood pressure is normal can lead to a relapse or worsening of hypertension. Choice C is incorrect as doubling the dose without healthcare provider guidance can be dangerous. Choice D is incorrect as taking medication with a high-fat meal can affect its absorption and efficacy.

5. What action should the nurse take to prevent aspiration in a client receiving enteral nutrition?

• A. Flush the feeding tube with water before and after feedings.
• B. Elevate the head of the bed to 30-45 degrees during feedings.
• C. Administer the feeding slowly.
• D. Check the client's weight daily.

Correct answer: B

Rationale: Elevating the head of the bed to 30-45 degrees during feedings is essential to prevent aspiration in clients receiving enteral nutrition. This positioning helps decrease the risk of regurgitation and aspiration by supporting proper digestion and aiding food passage through the gastrointestinal tract. Elevating the head of the bed is a standard precautionary measure recommended to reduce the chances of aspiration and should be consistently implemented during feedings to ensure client safety and optimal enteral nutrition delivery.

Similar Questions