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 client who has a new diagnosis of hypertension is being taught about dietary modifications by a nurse. Which of the following instructions should the nurse include?

• A. Limit fluid intake to 2 liters per day.
• B. Increase your intake of whole grains.
• C. Eat 3 large meals daily.
• D. Consume foods high in potassium.

Correct answer: B

Rationale: The correct answer is B: 'Increase your intake of whole grains.' Whole grains are beneficial for individuals with hypertension as they can help promote heart health. Whole grains are high in fiber, which can help lower blood pressure. Option A is incorrect as fluid intake should be adequate but not restricted to 2 liters per day. Option C is incorrect as it is recommended to have smaller, more frequent meals rather than 3 large meals to help manage hypertension. Option D is incorrect; although foods high in potassium can be beneficial for hypertension, the most appropriate dietary modification to include in this scenario is increasing whole grain intake.

3. A client in active labor is being assessed by a nurse. Which of the following findings should the nurse report to the provider?

• A. Contractions lasting 80 seconds.
• B. FHR baseline of 170/min.
• C. Early decelerations in the FHR.
• D. Temperature of 37.4°C (99.3°F).

Correct answer: B

Rationale: The correct answer is B because a baseline FHR of 170/min indicates fetal tachycardia, which needs further evaluation. Choice A about contractions lasting 80 seconds is within the normal range for active labor. Choice C, early decelerations in the FHR, are generally considered benign and do not require immediate reporting. Choice D, a temperature of 37.4°C (99.3°F), falls within normal limits for a laboring client and does not warrant immediate reporting.

4. A client with heart failure is being educated by a nurse about fluid restrictions. Which of the following instructions should the nurse include?

• A. Limit your fluid intake to 3 liters per day.
• B. Increase your fluid intake to 5 liters per day.
• C. Avoid drinking more than 1 liter of fluid per day.
• D. You can drink as much fluid as you want during meals.

Correct answer: C

Rationale: The correct answer is C: "Avoid drinking more than 1 liter of fluid per day." Clients with heart failure are typically advised to limit their fluid intake to around 1 liter per day to prevent fluid overload, which can worsen their condition. Choices A, B, and D are incorrect because they suggest fluid intakes that are higher than the recommended limit, which could lead to fluid retention and exacerbate heart failure symptoms.

5. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include?

• A. Critical pathways have unlimited timeframes for completion.
• B. Critical pathways are designed to decrease health care costs.
• C. Patients follow the critical pathway if variances occur.
• D. Budgets are used to create the critical pathway.

Correct answer: B

Rationale: The correct answer is B. Critical pathways are structured, multi-disciplinary plans of care designed to decrease health care costs and improve outcomes by standardizing and streamlining processes. Choice A is incorrect because critical pathways have specific timeframes for completion. Choice C is incorrect as patients are expected to follow the critical pathway without deviations to achieve optimal outcomes. Choice D is incorrect because budgets do not create critical pathways; rather, they are based on clinical guidelines and best practices.

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