Nursing Elites

1. A nurse is reviewing the plan of care for a client who is receiving chemotherapy for cancer. Which of the following interventions should the nurse include to prevent infection?

• A. Encourage the client to eat high-protein foods
• B. Encourage the client to drink 2 liters of fluid daily
• C. Instruct the client to use a soft toothbrush
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: C

Rationale: The correct answer is to instruct the client to use a soft toothbrush. Using a soft toothbrush helps prevent bleeding in clients receiving chemotherapy, who are at risk for mucositis. Encouraging the client to eat high-protein foods (Choice A) is important for overall health but not directly related to preventing infection. Encouraging the client to drink 2 liters of fluid daily (Choice B) is essential for hydration but does not specifically prevent infection. Instructing the client to use a mouthwash containing alcohol (Choice D) is contraindicated as alcohol-containing mouthwashes can cause irritation and dryness in the oral mucosa, increasing the risk of infection.

2. A nurse is providing discharge instructions for a client with diabetes. What is the most important teaching point?

• A. Monitor blood sugar levels weekly
• B. Administer insulin before meals as prescribed
• C. Take medication only when feeling unwell
• D. Monitor blood sugar only in the morning

Correct answer: B

Rationale: The correct answer is B: Administer insulin before meals as prescribed. This is the most important teaching point because insulin administration before meals helps manage blood sugar effectively in diabetic patients. Choice A is incorrect because monitoring blood sugar levels weekly may not provide timely information for managing diabetes. Choice C is incorrect as medications for diabetes should be taken as prescribed, not only when feeling unwell. Choice D is incorrect as blood sugar levels should be monitored at various times throughout the day, not just in the morning, to get a complete picture of the patient's condition.

3. How should a healthcare professional manage a patient with fluid overload?

• A. Restrict fluids and administer diuretics
• B. Increase fluid intake and provide oral diuretics
• C. Administer antibiotics and monitor weight
• D. Monitor weight and provide a low-sodium diet

Correct answer: A

Rationale: Corrected Question: When managing a patient with fluid overload, the appropriate approach involves restricting fluids and administering diuretics. This strategy helps remove excess fluid from the body and prevent complications associated with fluid overload. Choice B suggesting increasing fluid intake is incorrect as it would worsen the condition. Choice C, administering antibiotics, is unrelated to managing fluid overload. Choice D, monitoring weight and providing a low-sodium diet, is helpful but not as effective as fluid restriction and diuretics in managing fluid overload.

4. What should a person recommend to a client experiencing constipation?

• A. Increase fluid intake to prevent further dehydration
• B. Increase dietary fiber to promote regular bowel movements
• C. Administer a laxative to relieve constipation
• D. Encourage bed rest to allow for bowel function to return

Correct answer: B

Rationale: Increasing dietary fiber is an effective recommendation for clients experiencing constipation as it helps promote regular bowel movements. Choice A, increasing fluid intake, is also important but the most appropriate initial recommendation for constipation is to increase dietary fiber. Choice C, administering a laxative, should not be the first-line recommendation and is typically considered after dietary and lifestyle interventions. Choice D, encouraging bed rest, does not directly address constipation relief or prevention.

5. Which of the following is an early indication that a tracheostomy client requires suctioning?

• A. Bradycardia
• B. Irritability
• C. Hypotension
• D. Decreased respiratory rate

Correct answer: B

Rationale: Irritability is indeed an early sign that a tracheostomy client may require suctioning. When a tracheostomy client becomes irritable, it can indicate that there is a need for suctioning to clear the airway. Bradycardia (choice A) refers to a slow heart rate and is not typically a direct indication for suctioning. Hypotension (choice C) indicates low blood pressure and is not specifically related to the need for suctioning. Decreased respiratory rate (choice D) can be a sign of respiratory distress, but irritability is a more direct and early indication of the need for suctioning in a tracheostomy client.

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