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 nurse is providing discharge teaching to a client who has a prescription for digoxin. Which of the following instructions should the nurse include?

• A. Take your pulse before taking the medication.
• B. Take the medication with an antacid.
• C. Double the dose if you miss one.
• D. Take the medication with a high-fiber meal.

Correct answer: A

Rationale: The correct answer is A: 'Take your pulse before taking the medication.' When administering digoxin, it is crucial to monitor the pulse rate because digoxin can cause bradycardia (slow heart rate). Checking the pulse helps in assessing the heart rate before taking the medication, as bradycardia is a common side effect of digoxin. Choice B is incorrect because digoxin should not be taken with antacids, as they can reduce its absorption. Choice C is incorrect; the dose should never be doubled if a dose is missed. Choice D is incorrect because taking digoxin with a high-fiber meal can also affect its absorption. Therefore, the essential instruction for the client is to monitor the pulse before taking digoxin.

3. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

4. A client with renal calculi 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 calcium-rich foods.
• B. I should decrease my intake of calcium-rich foods.
• C. I should increase my intake of sodium-rich foods.
• D. I should decrease my intake of potassium-rich foods.

Correct answer: B

Rationale: The correct answer is B because decreasing the intake of calcium-rich foods can help manage and prevent the formation of renal calculi. Excessive calcium intake can contribute to the formation of these stones, so reducing calcium-rich foods is a key dietary modification for individuals with renal calculi. Choice A is incorrect as increasing calcium-rich foods can exacerbate the condition. Choice C is incorrect because increasing sodium-rich foods can lead to more stone formation due to increased calcium excretion. Choice D is incorrect as potassium-rich foods do not directly contribute to the formation of renal calculi.

5. A client receives discharge teaching on a new prescription for lisinopril. Which of the following instructions should be included?

• A. Avoid foods high in potassium.
• B. Take the medication with food.
• C. Increase your intake of salt.
• D. Take the medication at bedtime.

Correct answer: A

Rationale: The correct instruction that should be included when a client receives discharge teaching on a new prescription for lisinopril is to 'Avoid foods high in potassium.' Lisinopril, an ACE inhibitor, can lead to hyperkalemia by reducing potassium excretion. Therefore, clients taking lisinopril should be advised to avoid foods high in potassium to prevent potential complications associated with elevated potassium levels. Choices B, C, and D are incorrect because taking lisinopril with food, increasing salt intake, or taking the medication at bedtime are not specific instructions related to lisinopril therapy and may not be beneficial or necessary for the client's condition.

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