Nursing Elites

1. A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action?

• A. Implement a regular toileting schedule
• B. Encourage the client to wear athletic socks when ambulating
• C. Place all four bed rails in the upright position
• D. Require a family member to remain at the bedside

Correct answer: A

Rationale: Implementing a regular toileting schedule is an appropriate nursing action for a client at risk for falls. This action can help prevent accidents related to rushing to the bathroom. Encouraging the client to wear athletic socks when ambulating (Choice B) is not safe as it can increase the risk of slipping and falling. Placing all four bed rails in the upright position (Choice C) can lead to entrapment or falls when the client tries to get out of bed. Requiring a family member to remain at the bedside (Choice D) may not always be feasible and does not directly address fall prevention strategies like the toileting schedule.

2. How should a healthcare professional assess and manage a patient with ascites?

• A. Monitor abdominal girth and administer diuretics
• B. Administer pain relief and monitor fluid intake
• C. Restrict fluid intake and encourage bed rest
• D. Administer albumin and check electrolyte levels

Correct answer: A

Rationale: Correct! When managing a patient with ascites, monitoring abdominal girth is crucial as it helps assess the extent of fluid retention. Administering diuretics is also essential to help reduce fluid buildup in the body, thereby managing ascites effectively. Option B is incorrect as pain relief is not the primary intervention for ascites. Option C is incorrect as restricting fluid intake can worsen the condition by causing dehydration and further fluid imbalances. Option D is incorrect as administering albumin and checking electrolyte levels are not first-line interventions for managing ascites; these interventions may be considered in specific cases but are not the initial steps in managing ascites.

3. A client with moderate anxiety disorder is being taught stress management techniques by a nurse. Which response by the client indicates an understanding of the teaching?

• A. I will take a walk to reduce my anxiety
• B. I will imagine myself in a calm place when I can't concentrate
• C. I will meditate every other week
• D. I will cut back on my caffeine intake

Correct answer: B

Rationale: The correct answer is B because imagining oneself in a calm place is a relaxation technique that helps reduce anxiety. Walking, meditating every other week, or cutting back on caffeine intake may have their benefits, but they are not as directly related to the immediate management of anxiety as the visualization technique described in option B.

4. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?

• A. A history of gastroesophageal reflux disease.
• B. Receiving a formula with high osmolarity.
• C. Sitting in a high-Fowler's position during the feeding.
• D. A residual of 65 mL 1 hour postprandial.

Correct answer: A

Rationale: The correct answer is A: A history of gastroesophageal reflux disease. Clients with gastroesophageal reflux disease have a higher risk of aspiration during tube feeding due to the potential for reflux of stomach contents into the lungs. This increases the risk of aspiration pneumonia. Choices B, C, and D are incorrect. High osmolarity formulas may cause diarrhea but do not directly increase the risk of aspiration. Sitting in a high-Fowler's position actually reduces the risk of aspiration by promoting proper digestion and reducing the chance of regurgitation. A residual of 65 mL 1 hour postprandial is within an acceptable range and does not directly indicate a risk for aspiration.

5. Which intervention is essential when caring for a client with heart failure on fluid restriction?

• A. Encourage the client to drink water throughout the day
• B. Monitor the client's weight daily to assess fluid balance
• C. Limit fluid intake during meals
• D. Weigh the client once a week to assess fluid balance

Correct answer: B

Rationale: The correct answer is B: 'Monitor the client's weight daily to assess fluid balance.' When caring for a client with heart failure on fluid restriction, it is essential to monitor their weight daily to evaluate fluid balance accurately. This helps healthcare providers 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 water throughout the day contradicts fluid restriction. Limiting fluid intake during meals may not provide a comprehensive assessment of fluid balance, and weighing the client once a week is not frequent enough to detect rapid changes in fluid status that could worsen heart failure symptoms.

Similar Questions