Nursing Elites

1. A client is reinforcing teaching with a nurse about how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching?

• A. The client exhales deeply before inhaling
• B. The client attempts to elevate the cylinder by inhaling deeply
• C. The client inhales quickly through the spirometer
• D. The client inhales several short breaths

Correct answer: B

Rationale: The correct answer is B because inhaling deeply and slowly elevates the cylinder on the spirometer, promoting lung expansion. Choice A is incorrect as exhaling deeply before inhaling is not the correct technique for using an incentive spirometer. Choice C is incorrect as inhaling quickly through the spirometer does not promote optimal lung expansion. Choice D is incorrect as inhaling several short breaths does not facilitate the proper use of an incentive spirometer.

2. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client?

• A. Can you tell me who visited you today?
• B. What high school did you graduate from?
• C. Can you list your current medications?
• D. What did you have for breakfast yesterday?

Correct answer: B

Rationale: The correct answer is B: 'What high school did you graduate from?' Remote memory involves recalling past events, such as educational history, making option B the most appropriate question to assess this aspect of memory in an older adult with mild dementia. Option A pertains to recent memory. Option C focuses on short-term memory. Option D addresses recent memory as well.

3. What are the nursing interventions for a patient with fluid volume overload?

• A. Restrict fluid intake
• B. Monitor intake and output
• C. Administer diuretics as prescribed
• D. Elevate the head of the bed

Correct answer: A

Rationale: The correct nursing intervention for a patient with fluid volume overload is to restrict fluid intake. This helps to prevent further fluid accumulation in the body. Monitoring intake and output (choice B) is important to assess the patient's fluid balance but is not a direct intervention to address fluid volume overload. Administering diuretics as prescribed (choice C) is a medical intervention that may be ordered by a healthcare provider but should not be assumed as a nursing intervention without a prescription. Elevating the head of the bed (choice D) is a measure commonly used for patients with respiratory distress or to prevent aspiration but is not a direct intervention for fluid volume overload.

4. What are the complications of untreated fluid overload?

• A. Pulmonary edema and congestive heart failure
• B. Hypertension and electrolyte imbalance
• C. Liver failure and electrolyte imbalance
• D. Pulmonary embolism and dehydration

Correct answer: A

Rationale: Corrected Rationale: Untreated fluid overload can lead to complications such as pulmonary edema and congestive heart failure. Pulmonary edema occurs when excess fluid accumulates in the lungs, leading to difficulty breathing and potentially life-threatening respiratory distress. Congestive heart failure can result from the heart's inability to pump effectively due to the excess fluid volume, leading to symptoms such as fatigue, shortness of breath, and fluid retention. Choices B, C, and D are incorrect because hypertension, liver failure, pulmonary embolism, and dehydration are not the primary complications directly associated with untreated fluid overload.

5. A client undergoing chemotherapy for cancer is being taught about potential adverse effects of the treatment. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will avoid drinking water before meals
• B. I might experience hair loss during treatment
• C. I might experience an increase in appetite
• D. I should expect my appetite to increase

Correct answer: B

Rationale: The correct answer is B because hair loss is a common adverse effect of chemotherapy. Options A, C, and D are incorrect. Avoiding drinking water before meals, experiencing an increase in appetite, or expecting appetite to increase are not related to the potential adverse effects of chemotherapy.

Similar Questions