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 has Raynaud's disease. Which of the following actions should the nurse take?

• A. Provide information about stress management.
• B. Maintain a warm temperature in the client's room.
• C. Administer epinephrine for acute episodes.
• D. Give glucocorticoid steroids twice a day.

Correct answer: A

Rationale: Corrected Rationale: Providing information about stress management is essential when caring for a client with Raynaud's disease because stress can trigger episodes. Stress management techniques can help the client avoid triggers and reduce the frequency of episodes. Choice B is incorrect because maintaining a warm temperature, rather than a cool one, helps prevent vasoconstriction and can be beneficial for clients with Raynaud's disease. Choice C is incorrect because epinephrine is not a standard treatment for Raynaud's disease; it is more commonly used for severe allergic reactions. Choice D is incorrect because glucocorticoid steroids are not typically used in the management of Raynaud's disease.

3. What is the best intervention for a patient presenting with respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Reposition the patient
• D. Provide humidified air

Correct answer: A

Rationale: Administering oxygen is the most critical intervention for a patient in respiratory distress as it helps improve oxygenation levels. Oxygen therapy aims to increase oxygen saturation in the blood, providing relief and support during episodes of respiratory distress. Administering bronchodilators may be beneficial in some cases, but oxygen therapy takes precedence in addressing the underlying issue of inadequate oxygenation. Repositioning the patient may help optimize ventilation but does not directly address the primary need for increased oxygen. Providing humidified air can offer comfort but does not address the urgent need for improved oxygen levels in a patient experiencing respiratory distress.

4. A nurse is caring for a client who is 3 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider?

• A. Stoma that is red and moist
• B. Purulent drainage from the stoma
• C. Stoma that is dry and purple
• D. Mild swelling around the stoma

Correct answer: C

Rationale: A dry, purple stoma is abnormal and may indicate compromised blood flow, which should be reported to the provider. A red and moist stoma is a normal finding postoperatively. Purulent drainage from the stoma indicates infection and should also be reported. Mild swelling around the stoma is common in the early postoperative period and does not typically require immediate reporting.

5. A client with a new diagnosis of diabetes mellitus is being taught about foot care by a nurse. Which of the following instructions should the nurse include?

• A. Soak your feet in warm water every day to prevent dryness.
• B. Trim your toenails straight across to prevent injury.
• C. Apply lotion between your toes after bathing.
• D. Wear cotton socks to keep your feet dry.

Correct answer: B

Rationale: The correct answer is B: 'Trim your toenails straight across to prevent injury.' In clients with diabetes, trimming toenails straight across is essential to prevent ingrown toenails and injury. Choice A is incorrect because soaking feet in warm water can lead to dryness, which is not recommended for diabetic foot care. Choice C is incorrect as applying lotion between the toes can create excess moisture, increasing the risk of fungal infections. Choice D is incorrect because although cotton socks are recommended, the primary purpose is to prevent moisture buildup, not specifically to keep the feet dry.

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