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 teaching a client who has heart failure about fluid restrictions. Which of the following instructions should the nurse include?

• A. Limit fluid intake to 3 liters per day
• B. Limit fluid intake to 1-2 liters per day
• C. Drink 4 liters of water per day
• D. Restrict water intake to 1 liter per day

Correct answer: B

Rationale: The correct answer is B: 'Limit fluid intake to 1-2 liters per day.' For clients with heart failure, fluid restriction is essential to prevent fluid overload. Restricting fluid intake to 1-2 liters per day helps maintain fluid balance and prevents exacerbation of heart failure symptoms. Choices A, C, and D are incorrect because consuming 3 liters, 4 liters, or limiting water intake to 1 liter per day, respectively, can lead to fluid overload in clients with heart failure.

3. A nurse is preparing a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report?

• A. Hgb 12.8 g/dl.
• B. Potassium 4.2 mEq/L.
• C. RBC 4.4 million/mm3.
• D. Platelets 100,000/mm3.

Correct answer: D

Rationale: The correct answer is D: "Platelets 100,000/mm3." A platelet count of 100,000/mm3 is low and increases the client's risk for bleeding, which is crucial information to communicate during the change-of-shift report. Choices A, B, and C provide values within normal ranges and are not directly related to the client's postoperative status or risk for complications. Therefore, they are not the priority information to include in the report.

4. A nurse is performing postmortem care for a client prior to the arrival of the client's family for viewing of the body. Which of the following actions should the nurse take?

• A. Apply moisturizing lotion to the skin
• B. Turn off the lights
• C. Remove all jewelry
• D. Gently close the client's eyelids

Correct answer: D

Rationale: The correct action the nurse should take is to gently close the client's eyelids. This is a respectful and common practice in postmortem care before allowing the family to view the body. Applying moisturizing lotion to the skin is unnecessary and may not be appropriate at this time. Turning off the lights might not be necessary and could impact the viewing environment for the family. While removing all jewelry is generally a good practice, it is not as crucial as gently closing the client's eyelids for postmortem care.

5. What is the priority nursing action for a client with dehydration?

• A. Administer oral fluids
• B. Monitor electrolyte levels
• C. Administer antiemetics as needed
• D. Encourage bed rest

Correct answer: B

Rationale: The priority nursing action for a client with dehydration is to monitor electrolyte levels. Dehydration can cause imbalances in electrolytes such as sodium and potassium, affecting essential bodily functions. Monitoring electrolyte levels is crucial to promptly identify and correct any imbalances. While administering oral fluids (Choice A) is vital in treating dehydration, monitoring electrolyte levels takes precedence as it directly addresses the underlying imbalance. Administering antiemetics (Choice C) may be necessary for nausea and vomiting but is not the priority over electrolyte monitoring. Encouraging bed rest (Choice D) can conserve energy but is not as critical as monitoring electrolyte levels to prevent complications related to electrolyte imbalances.

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