Nursing Elites

1. A client with heart failure is being assessed by a nurse. Which of the following findings indicates the client is experiencing fluid overload?

• A. Dry, hacking cough
• B. Bounding peripheral pulses
• C. Decreased urinary output
• D. Weight loss of 1 kg in 24 hours

Correct answer: C

Rationale: In clients with heart failure, decreased urinary output is a classic sign of fluid overload. The kidneys try to compensate for the increased volume by reducing urine output, leading to fluid retention. A dry, hacking cough (choice A) is more indicative of heart failure complications like pulmonary edema. Bounding peripheral pulses (choice B) are a sign of increased volume, but not specifically fluid overload. Weight loss of 1 kg in 24 hours (choice D) is not indicative of fluid overload but rather rapid fluid loss.

2. A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of the following dietary recommendations should the nurse make?

• A. Increase your intake of high-fiber foods.
• B. Avoid foods that are high in fat.
• C. Increase your intake of dairy products.
• D. Drink carbonated beverages to help with bloating.

Correct answer: B

Rationale: The correct answer is B: "Avoid foods that are high in fat." Clients with IBS should avoid foods high in fat as they can exacerbate symptoms such as abdominal pain, bloating, and diarrhea. High-fiber foods, choice A, can sometimes worsen symptoms in individuals with IBS. Increasing intake of dairy products, choice C, may also worsen symptoms for some individuals with IBS, especially if they are lactose intolerant. Drinking carbonated beverages, choice D, can contribute to bloating and gas, making symptoms worse for individuals with IBS.

3. A nurse is providing discharge teaching to a client who has a wound infection. Which of the following information should the nurse include about home care?

• A. Soak the wound in warm water every day
• B. Use hydrogen peroxide to clean the wound
• C. Apply a cold compress to the wound
• D. Keep the wound covered with a dry dressing

Correct answer: D

Rationale: The correct answer is D: 'Keep the wound covered with a dry dressing.' When providing care for a wound infection, it is essential to keep the wound covered with a dry dressing to prevent further contamination and promote healing. Soaking the wound in warm water (choice A) can introduce moisture and increase the risk of infection. Using hydrogen peroxide (choice B) can be too harsh and may slow down the healing process by damaging healthy tissue. Applying a cold compress (choice C) is not typically recommended for wound infections, as it may not provide the necessary environment for healing.

4. A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

• A. Raise the side rails on both sides of the client's bed during repositioning.
• B. Reposition the client without assistive devices.
• C. Discuss the client's preferences to determine a repositioning schedule.
• D. Evaluate the client's ability to help with repositioning.

Correct answer: D

Rationale: The correct answer is to evaluate the client's ability to help with repositioning. When caring for a client who had a stroke, assessing their ability to participate in repositioning is crucial for promoting safety and encouraging their involvement in their care. This evaluation helps determine the level of assistance needed and supports the client's autonomy. Option A is incorrect because raising the side rails alone does not address the client's active involvement in repositioning. Option B is incorrect as using assistive devices may be necessary for safe repositioning. Option C is incorrect as discussing preferences is important but does not directly address the client's ability to assist in repositioning.

5. A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head uncovered.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent irritation during phototherapy, as exposure to light can increase the risk of skin breakdown. Feeding the infant glucose water is unnecessary and not indicated for jaundice treatment. Keeping the infant's head uncovered allows the light to reach the skin effectively. Applying lotion to the newborn every 4 hours can interfere with the effectiveness of phototherapy and is not recommended.

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