Nursing Elites

1. A client with heart failure is being taught about dietary modifications by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will increase my intake of canned vegetables.
• B. I will limit my daily sodium intake to 2 grams.
• C. I will increase my intake of whole grains.
• D. I will reduce my intake of processed meats.

Correct answer: D

Rationale: The correct answer is 'D: I will reduce my intake of processed meats.' This choice indicates an understanding of the teaching because processed meats are high in sodium, which can worsen heart failure due to fluid retention. Choices A, B, and C do not directly address the issue of reducing sodium intake, which is crucial for clients with heart failure. Increasing canned vegetable intake (A) may not always be advisable due to potential high sodium content in canned products. Limiting sodium intake to 2 grams daily (B) is a good practice, but it's more specific to sodium restriction rather than addressing the source of sodium like processed meats. Increasing whole grains (C) is generally beneficial but does not directly relate to reducing sodium intake in heart failure clients.

2. A nurse is caring for a client who has a Clostridium difficile infection. Which of the following precautions should the nurse implement?

• A. Place the client in a negative pressure room
• B. Wear an N95 respirator mask when entering the room
• C. Wear a gown and gloves when providing care to the client
• D. Place a face mask on the client

Correct answer: C

Rationale: The correct precaution to implement when caring for a client with Clostridium difficile infection is to wear a gown and gloves when providing care. Clostridium difficile is primarily spread through contact with feces, so wearing personal protective equipment like gowns and gloves is crucial in preventing the spread of the infection. Placing the client in a negative pressure room (Choice A) is not necessary for Clostridium difficile. While wearing an N95 respirator mask (Choice B) is important for airborne precautions, it is not required for Clostridium difficile. Placing a face mask on the client (Choice D) is not a standard precaution for preventing the spread of Clostridium difficile.

3. A healthcare provider is assessing a client who has COPD and is receiving oxygen therapy at 2 L/min via nasal cannula. Which of the following findings should the provider report?

• A. Oxygen saturation of 95%.
• B. Productive cough with clear sputum.
• C. Respiratory rate of 22/min.
• D. Client reports dyspnea.

Correct answer: D

Rationale: The correct answer is D. Dyspnea in a client with COPD receiving oxygen should be reported as it may indicate worsening respiratory status. Oxygen saturation of 95% is within the expected range for a client receiving oxygen therapy and does not require immediate reporting. A productive cough with clear sputum is a common symptom in clients with COPD and does not necessarily warrant urgent reporting. A respiratory rate of 22/min is also within normal limits and does not raise immediate concerns in this scenario.

4. A nurse is planning care for a client who has a new diagnosis of heart failure. Which of the following interventions should the nurse include in the plan of care?

• A. Limit the client's fluid intake to 1,500 mL per day.
• B. Encourage the client to walk every 2 hours.
• C. Monitor the client's weight daily.
• D. Administer oxygen via nasal cannula at 2 L/min.

Correct answer: C

Rationale: The correct intervention the nurse should include in the plan of care for a client with heart failure is to monitor the client's weight daily. Daily weight monitoring is essential to assess fluid balance and detect any signs of worsening heart failure. Limiting fluid intake to 1,500 mL per day (Choice A) may be appropriate in some cases, but it is not the initial priority for this client. Encouraging the client to walk every 2 hours (Choice B) is generally beneficial for mobility but may not be directly related to managing heart failure. Administering oxygen via nasal cannula at 2 L/min (Choice D) is a supportive measure for hypoxia but does not directly address heart failure management.

5. A nurse is assessing a newborn who is 12 hours old. Which of the following findings should the nurse report to the provider?

• A. Heart rate 140/min.
• B. A bulging anterior fontanel.
• C. Respiratory rate 50/min.
• D. Blood glucose 45 mg/dL.

Correct answer: D

Rationale: A blood glucose level of 45 mg/dL is below the normal range for a newborn and indicates hypoglycemia, which can lead to serious complications if left untreated. Therefore, this finding should be reported to the provider immediately. Choices A, B, and C are within normal ranges for a newborn and do not require immediate reporting. A heart rate of 140/min, a bulging anterior fontanel, and a respiratory rate of 50/min are all common findings in a newborn and do not raise immediate concerns.

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