Nursing Elites

1. A nurse is collecting data from a male client who is scheduled for a left inguinal herniorrhaphy. Which of the following findings is the priority for the nurse to report to the provider?

• A. High blood pressure
• B. Decreased bowel sounds
• C. Constipation
• D. Difficulty urinating

Correct answer: D

Rationale: The correct answer is 'Difficulty urinating.' This finding is crucial to report promptly as it can indicate a complication, such as urinary retention or injury to the urinary tract, which are significant concerns post-hernia surgery. High blood pressure (Choice A) may require monitoring but is not as urgent as difficulty urinating. Decreased bowel sounds (Choice B) and constipation (Choice C) are common after surgery and may resolve with appropriate interventions but are not as critical as addressing difficulty urinating.

2. A client has undergone a myelogram, and a nurse is providing post-procedure care. Which action should be included in the nursing care plan?

• A. Encourage ambulation after the procedure
• B. Maintain the prone position for 12 hours
• C. Evaluate the client's distal pulses on the affected side
• D. Encourage oral fluid intake

Correct answer: C

Rationale: The correct action to include in the nursing care plan for a client post-myelogram is to evaluate the client's distal pulses on the affected side. This is crucial to assess circulation and detect any potential complications such as impaired blood flow or vascular issues. Encouraging ambulation after the procedure (Choice A) is not typically recommended immediately post-myelogram, as the client may need to rest. Maintaining the prone position for 12 hours (Choice B) is an outdated practice and is no longer part of standard care post-myelogram. Encouraging oral fluid intake (Choice D) is generally beneficial for hydration but is not a specific priority related to post-myelogram care.

3. How should a healthcare provider manage a patient with sepsis?

• A. Administer IV antibiotics
• B. Monitor vital signs
• C. Administer fluids
• D. All of the above

Correct answer: D

Rationale: Managing a patient with sepsis requires a multi-faceted approach. Administering IV antibiotics is crucial to combat the underlying infection. Monitoring vital signs such as heart rate, blood pressure, respiratory rate, and temperature helps assess the patient's response to treatment and identify any deterioration. Administering fluids is essential to maintain adequate blood pressure and organ perfusion. Therefore, all the options are integral components of sepsis management, making 'All of the above' the correct answer. Choices A, B, and C are all essential in the comprehensive care of a patient with sepsis. Omitting any of these aspects can lead to suboptimal outcomes, as each plays a critical role in addressing different aspects of sepsis management.

4. A client with heart failure is on a fluid restriction. What should the nurse include in the discharge teaching?

• A. Encourage the client to drink more water to stay hydrated
• B. Monitor the client's weight daily
• C. Avoid drinking water after 6 PM
• D. Monitor fluid intake only during meals

Correct answer: B

Rationale: The correct answer is B: 'Monitor the client's weight daily.' In clients with heart failure on fluid restriction, monitoring daily weight is crucial to track fluid balance. This allows healthcare providers to assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink more water contradicts the fluid restriction; avoiding drinking water after 6 PM is not specific to managing fluid restriction; and monitoring fluid intake only during meals does not provide a comprehensive assessment of fluid balance throughout the day.

5. Which lifestyle modification should be emphasized for a client with hypertension?

• A. Increase sodium intake
• B. Reduce caffeine and alcohol intake
• C. Eat carbohydrate-rich meals
• D. Increase protein intake

Correct answer: B

Rationale: The correct answer is to reduce caffeine and alcohol intake for a client with hypertension. Caffeine and alcohol can increase blood pressure, so reducing their intake can help manage hypertension. Increasing sodium intake (Choice A) is not recommended for hypertension as it can lead to fluid retention and increased blood pressure. Eating carbohydrate-rich meals (Choice C) is also not ideal as excessive carbohydrates can contribute to weight gain, which can worsen hypertension. Similarly, increasing protein intake (Choice D) is not a primary focus for managing hypertension unless a specific protein deficiency is present.

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