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 reports severe pain unrelieved by pain medication in a limb with traction. What is the nurse's priority?

• A. Increase the dosage of pain medication.
• B. Assess for compartment syndrome.
• C. Wait for the healthcare provider to address the issue.
• D. Reposition the client to alleviate the pain.

Correct answer: B

Rationale: The correct answer is B: Assess for compartment syndrome. Severe unrelieved pain in a limb with traction can be a sign of compartment syndrome, a surgical emergency. Prompt assessment is crucial to prevent potential complications. Increasing pain medication dosage without addressing the underlying cause may delay necessary interventions. Waiting for the healthcare provider may lead to a critical delay in treatment. Repositioning the client may not alleviate the pain if it is due to compartment syndrome, and it is crucial to assess for this condition first.

3. Which intervention is essential when caring for a patient with a nasogastric (NG) tube?

• A. Suction the NG tube every 4 hours.
• B. Check the placement of the NG tube before each feeding.
• C. Flush the NG tube with water before and after each medication administration.
• D. Remove the NG tube once the patient feels comfortable.

Correct answer: B

Rationale: Checking the placement of the NG tube before each feeding is crucial to ensure it is correctly positioned and safe to use. Option A is incorrect as routine suctioning can lead to complications and should only be done as needed. Option C is not necessary unless there are specific instructions for flushing. Option D is incorrect as the NG tube should only be removed by healthcare professionals based on medical criteria, not solely based on the patient's comfort.

4. A client who is 97 years old has successfully been treated for heart failure and is found not breathing. There is no DNR order in place. What should the nurse do?

• A. Notify the family and await further instructions.
• B. Initiate CPR and call for emergency assistance.
• C. Allow the family to make decisions about care.
• D. Follow the family's wishes and perform no interventions.

Correct answer: B

Rationale: In this scenario, with no DNR order in place and the client not breathing, the nurse should initiate CPR and call for emergency assistance. Option A is incorrect as immediate action is required in the absence of breathing. Option C is incorrect as the nurse should act promptly to provide life-saving measures. Option D is incorrect because the nurse's primary duty is to provide care in the absence of a directive preventing intervention.

5. What is a recommended nursing action for a client who experiences short-term memory loss after Electroconvulsive Therapy (ECT)?

• A. Provide cognitive-behavioral therapy
• B. Offer frequent orientation and reassurance
• C. Administer a sedative to improve memory recall
• D. Refer the client to a neurologist for further evaluation

Correct answer: B

Rationale: The correct nursing action for a client experiencing short-term memory loss after ECT is to offer frequent orientation and reassurance. This helps the client feel supported and aids in memory retention. Providing cognitive-behavioral therapy (Choice A) may be beneficial for other conditions but is not the primary intervention for memory loss post-ECT. Administering a sedative (Choice C) is not recommended as it may further affect memory recall. Referring the client to a neurologist (Choice D) for further evaluation is not the initial action needed; offering support and orientation should be the first approach to manage memory issues post-ECT.

Similar Questions