Nursing Elites

1. A nurse is reviewing the medical records of a client with chronic heart failure. What dietary recommendation should the nurse make?

• A. Follow a 3g sodium diet.
• B. Drink at least 3 liters of fluid per day.
• C. Place the client's lower extremities on two pillows.
• D. Maintain the client's oxygen saturation at 89%.

Correct answer: A

Rationale: The correct answer is A: Follow a 3g sodium diet. For clients with chronic heart failure, limiting sodium intake is crucial to prevent fluid retention and exacerbation of heart failure symptoms. High sodium intake can lead to fluid buildup, causing the heart to work harder. Choices B, C, and D are incorrect. Drinking excessive fluid can worsen fluid retention in heart failure, elevating the workload of the heart. Placing the client's lower extremities on two pillows is a positioning intervention to alleviate edema, not a dietary recommendation. Maintaining oxygen saturation at 89% is more related to respiratory status rather than dietary management of chronic heart failure.

2. A nurse is caring for a client who is 36 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 92/min
• B. Serosanguineous wound drainage
• C. Yellow wound drainage
• D. Blood pressure of 118/76 mm Hg

Correct answer: C

Rationale: Yellow wound drainage can indicate infection, especially 36 hours postoperative, and should be reported to the provider promptly. Serosanguineous drainage is a normal finding in the early stages of wound healing, and a heart rate of 92/min and a blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client. Therefore, the nurse should prioritize reporting the yellow wound drainage as it may require immediate intervention.

3. How should fluid overload in a patient with heart failure be managed?

• A. Administer diuretics
• B. Increase fluid intake
• C. Provide oral fluids
• D. Provide chest physiotherapy

Correct answer: A

Rationale: Administering diuretics is the appropriate management for fluid overload in a patient with heart failure. Diuretics help to reduce fluid retention by increasing urine output, thereby alleviating the fluid overload. Choices B, C, and D are incorrect. Increasing fluid intake would worsen the condition by adding more fluid to an already overloaded system. Providing oral fluids is not specific enough to address the excess fluid in the body, and chest physiotherapy is not indicated for managing fluid overload in heart failure patients.

4. A nurse is caring for a client who has a new prescription for spironolactone. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the medication?

• A. Serum sodium.
• B. Serum calcium.
• C. Serum potassium.
• D. Serum glucose.

Correct answer: C

Rationale: Corrected Rationale: Spironolactone is a potassium-sparing diuretic, so serum potassium should be monitored to evaluate its effectiveness. Monitoring serum potassium levels is crucial because spironolactone can cause hyperkalemia as a side effect. Serum sodium, serum calcium, and serum glucose levels are not directly affected by spironolactone and would not provide an accurate assessment of the medication's effectiveness.

5. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?

• A. Consume food high in bran fiber.
• B. Increase intake of milk products.
• C. Sweeten foods with fructose corn syrup.
• D. Increase foods high in gluten.

Correct answer: A

Rationale: The correct recommendation for a client with irritable bowel syndrome is to consume food high in bran fiber. Bran fiber promotes regularity and can help reduce symptoms of IBS. Choices B, C, and D are incorrect because increasing milk products, sweetening foods with fructose corn syrup, and consuming foods high in gluten can exacerbate symptoms of irritable bowel syndrome in some individuals.

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