Nursing Elites

1. A nurse is planning care for a client who has cirrhosis. Which of the following interventions should the nurse include?

• A. Limit the client's sodium intake to 4 grams per day.
• B. Measure the client's abdominal girth daily.
• C. Monitor the client's urine specific gravity every 12 hours.
• D. Encourage the client to drink 3 liters of fluid per day.

Correct answer: B

Rationale: The correct answer is to measure the client's abdominal girth daily. Measuring abdominal girth helps monitor for ascites, a common complication of cirrhosis. Limiting sodium intake is important in cirrhosis but there is no specific value given, making choice A less precise. Monitoring urine specific gravity is not directly related to cirrhosis management, making choice C incorrect. Encouraging the client to drink 3 liters of fluid per day may not be suitable for all patients with cirrhosis, especially those with fluid restrictions, so choice D is not the most appropriate intervention.

2. A nurse is planning to administer a blood transfusion to a client. Which of the following should the nurse do to prevent an adverse transfusion reaction?

• A. Verify the client's blood type with the provider's prescription
• B. Ensure the client's consent for the transfusion is on file
• C. Administer a diuretic prior to starting the transfusion
• D. Check the client's temperature prior to the transfusion

Correct answer: A

Rationale: The correct answer is to verify the client's blood type with the provider's prescription. This is crucial to prevent an adverse transfusion reaction due to incompatibility. Ensuring the blood type matches before starting the transfusion is a standard safety practice. Option B, ensuring client consent, is important but not directly related to preventing a transfusion reaction. Option C, administering a diuretic, is unnecessary and can be harmful in this context. Option D, checking the client's temperature, is important for general assessment but not specifically focused on preventing a transfusion reaction.

3. A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy. Which of the following information should the charge nurse include?

• A. The proxy should make health care decisions for the client regardless of the client's ability to do so
• B. The proxy can make financial decisions if the need arises
• C. The proxy can make treatment decisions if the client is under anesthesia
• D. The proxy should manage legal issues for the client

Correct answer: C

Rationale: The correct answer is C because the health care proxy can make treatment decisions for the client if the client is under anesthesia. This aligns with the concept of durable power of attorney for health care, where the proxy is authorized to make health care decisions when the client is unable to do so. Choices A, B, and D are incorrect. Choice A is incorrect because the proxy should make health care decisions only when the client is unable to do so. Choice B is incorrect as financial decisions are not typically within the scope of a health care proxy. Choice D is incorrect as managing legal issues is not the primary role of a health care proxy.

4. A nurse is caring for a client who has received a new diagnosis of terminal cancer. The client tells the nurse, 'I just want to live long enough to see my child graduate.' The nurse should identify that the client is in which of the following stages of grief?

• A. Denial
• B. Bargaining
• C. Acceptance
• D. Anger

Correct answer: B

Rationale: The client expressing a desire to live long enough to see their child graduate is an example of bargaining, which is a stage of grief where individuals attempt to negotiate for more time or different outcomes. Denial refers to refusing to accept the reality of the situation, acceptance involves coming to terms with the diagnosis, and anger is feeling frustrated and upset about the situation. Therefore, the correct answer is 'Bargaining.'

5. A client has a nasogastric tube and is receiving intermittent enteral feedings. Which of the following actions should the nurse take to prevent aspiration?

• A. Administer a bolus feeding over 10 minutes.
• B. Elevate the head of the bed to 45 degrees during feedings.
• C. Flush the tube with 10 mL of sterile water before feedings.
• D. Position the client on the left side during feedings.

Correct answer: B

Rationale: To prevent aspiration in clients with a nasogastric tube receiving intermittent enteral feedings, the nurse should elevate the head of the bed to 45 degrees during feedings. This position helps reduce the risk of regurgitation and aspiration of the feeding contents. Administering a bolus feeding over 10 minutes (choice A) may not prevent aspiration as effectively as elevating the head of the bed. Flushing the tube with sterile water before feedings (choice C) is important for tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (choice D) is not the recommended action to prevent aspiration; elevating the head of the bed is more effective.

Similar Questions