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 experiencing acute alcohol withdrawal. Which of the following interventions should the nurse implement?

• A. Provide a low-sodium diet.
• B. Administer lorazepam as prescribed.
• C. Keep the client in a supine position.
• D. Place the client in restraints as prescribed.

Correct answer: B

Rationale: Administering lorazepam is the appropriate intervention for a client experiencing acute alcohol withdrawal. Lorazepam helps reduce agitation and prevent complications during this withdrawal phase. Choice A, providing a low-sodium diet, is not directly related to managing alcohol withdrawal symptoms. Choice C, keeping the client in a supine position, is not necessary and may not address the client's withdrawal symptoms. Choice D, placing the client in restraints, should only be considered if the client is at risk of harming themselves or others, but it is not the primary intervention for managing alcohol withdrawal.

3. A nurse is teaching a prenatal class about infections. Which statement by a participant indicates a need for further teaching?

• A. I can clean the cat's litter box during pregnancy.
• B. I can visit someone with the flu after receiving the vaccine.
• C. I should take antibiotics for viral infections.
• D. I should wash my hands after gardening.

Correct answer: C

Rationale: The correct answer is C. This statement indicates a need for further teaching because antibiotics are ineffective against viral infections. It is important to educate the participant that antibiotics are only effective against bacterial infections, not viral ones. Choices A, B, and D are correct statements that promote good hygiene practices and infection prevention during pregnancy.

4. A client with deep vein thrombosis receiving heparin therapy needs monitoring. Which test should the nurse use to regulate the medication dosage?

• A. Prothrombin time (PT)
• B. International Normalized Ratio (INR)
• C. Activated partial thromboplastin time (aPTT)
• D. Fibrinogen levels

Correct answer: C

Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). aPTT is specifically used to monitor and regulate heparin therapy as it assesses the intrinsic pathway of coagulation, which heparin affects. Options A and B, Prothrombin time (PT) and International Normalized Ratio (INR), are used to monitor warfarin therapy, not heparin. Option D, Fibrinogen levels, is not the primary test used to monitor heparin therapy.

5. A nurse is providing discharge teaching to a client who had a stroke. What instruction should the nurse provide?

• A. Avoid lifting more than 5 pounds.
• B. Perform range-of-motion exercises daily.
• C. Take medications at the same time every day.
• D. Monitor blood pressure daily.

Correct answer: C

Rationale: The correct answer is C: 'Take medications at the same time every day.' Consistency in medication administration is crucial for stroke recovery to maintain therapeutic drug levels in the body. Choice A, 'Avoid lifting more than 5 pounds,' though important to prevent strain, is not directly related to medication adherence. Choice B, 'Perform range-of-motion exercises daily,' is beneficial for overall recovery but is not specific to medication management. Choice D, 'Monitor blood pressure daily,' is important but does not address the key aspect of medication regimen adherence.

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