Nursing Elites

1. A client with cirrhosis and ascites requires a care plan. Which intervention should the nurse include?

• A. Increase the client's sodium intake
• B. Increase the client's saturated fat intake
• C. Decrease the client's carbohydrate intake
• D. Decrease the client's fluid intake

Correct answer: D

Rationale: In cirrhosis with ascites, decreasing fluid intake is crucial to manage the condition. This helps prevent further fluid accumulation in the abdomen. Increasing sodium intake (Choice A) can worsen fluid retention and edema. Increasing saturated fat intake (Choice B) is not recommended as it can contribute to liver damage. Decreasing carbohydrate intake (Choice C) is not directly related to managing ascites in cirrhosis.

2. A client who has been having frequent tonic-clonic seizures is being admitted by a nurse. Which of the following actions should the nurse add to the client's plan of care?

• A. Apply restraints
• B. Use soft wristbands
• C. Wrap blankets around side rails
• D. Administer sedatives

Correct answer: C

Rationale: The correct action the nurse should add to the client's plan of care is to wrap blankets around side rails. This helps prevent injury during seizures by providing a cushioned surface against the hard rails. Applying restraints (Choice A) is not recommended as it can cause harm during a seizure. Using soft wristbands (Choice B) may not provide adequate protection against injury. Administering sedatives (Choice D) is not typically indicated for managing tonic-clonic seizures as they require specific anti-seizure medications.

3. A community health nurse is reviewing primary prevention strategies for West Nile virus with a group of clients in a rural health clinic. Which of the following instructions should the nurse include?

• A. Avoid exposure to deer ticks.
• B. Eliminate areas of standing water.
• C. Use a respiratory mask when cleaning bird coops.
• D. Plan outdoor activities after dusk.

Correct answer: B

Rationale: The correct answer is B: 'Eliminate areas of standing water.' This is an essential primary prevention strategy for West Nile virus as it helps prevent the breeding of mosquitoes that spread the virus. Choices A, C, and D are incorrect. Avoiding exposure to deer ticks is more relevant for Lyme disease, using a respiratory mask when cleaning bird coops is not a primary prevention strategy for West Nile virus, and planning outdoor activities after dusk does not directly address the prevention of West Nile virus transmission.

4. A nurse enters a client's room and finds the client pulseless. The client's living will requests no resuscitation be performed, but the provider has not written the prescription. Which of the following actions should the nurse take?

• A. Administer emergency medications without performing CPR
• B. Begin CPR
• C. Call the provider for a do-not-resuscitate (DNR) order
• D. Respect the client's wishes, and do not attempt CPR

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to begin CPR. In the absence of a written DNR order by the provider, the nurse is ethically and legally obligated to initiate CPR to attempt to save the client's life. Administering emergency medications without CPR (Choice A) may not address the immediate need for life-saving measures. Calling the provider for a DNR order (Choice C) may cause a delay in providing necessary resuscitative measures. Respecting the client's wishes and not attempting CPR (Choice D) goes against the nurse's duty to provide immediate life-saving interventions in the absence of a DNR order.

5. A patient with heart failure needs education on fluid restrictions. What is the most important information to provide?

• A. Monitor the patient's weight daily.
• B. Provide the patient with a fluid restriction plan.
• C. Instruct the patient to avoid salty foods.
• D. Encourage the patient to increase fluid intake.

Correct answer: B

Rationale: The most important information to provide to a patient with heart failure regarding fluid restrictions is to provide them with a fluid restriction plan. This plan helps the patient manage their fluid intake effectively, which is crucial in preventing complications associated with heart failure. Monitoring weight daily can be a part of the plan but is not the most important. Instructing the patient to avoid salty foods is beneficial but not as crucial as having a structured fluid restriction plan. Encouraging the patient to increase fluid intake would be counterproductive and potentially harmful in a patient with heart failure.

Similar Questions