Nursing Elites

1. A nurse is teaching a client who is undergoing chemotherapy about measures to prevent infection. Which of the following instructions should the nurse include?

• A. Avoid crowded places
• B. Wear a mask at home
• C. Drink unfiltered water
• D. Avoid washing hands frequently

Correct answer: A

Rationale: The correct instruction the nurse should include is to advise the client to avoid crowded places. Immunocompromised clients undergoing chemotherapy are at a higher risk of infections, so avoiding crowded places can help reduce exposure to pathogens. Wearing a mask at home is not necessary unless someone in the household is sick. Drinking unfiltered water can introduce harmful bacteria, increasing the risk of infection. Avoiding washing hands frequently is incorrect as hand hygiene is crucial in preventing the spread of infections.

2. Which intervention is most important for a client with chronic heart failure?

• A. Encourage fluid intake to prevent dehydration
• B. Monitor the client's weight daily to assess fluid balance
• C. Limit sodium intake to reduce fluid retention
• D. Restrict daily activity to prevent fatigue

Correct answer: B

Rationale: The correct answer is to monitor the client's weight daily to assess fluid balance in clients with chronic heart failure. Monitoring weight helps in detecting fluid retention or fluid loss, which is crucial in managing heart failure. Encouraging fluid intake to prevent dehydration (choice A) may worsen fluid overload in heart failure patients. Limiting sodium intake (choice C) is essential but not the most important intervention compared to monitoring weight. Restricting daily activity (choice D) is not recommended as it is important for clients with heart failure to engage in appropriate levels of physical activity to maintain their overall health.

3. The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see first?

• A. A 12-year-old oozing blood from a laceration on the left thumb due to a cut from a rusty metal can
• B. A 19-year-old with a fever of 103.8°F who is able to identify her sister but not the place and time
• C. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain
• D. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL

Correct answer: B

Rationale: The correct answer is B. A 19-year-old with a fever of 103.8°F who is confused and unable to orient to place and time likely has a severe infection or a serious medical condition affecting the central nervous system. This client needs immediate attention as altered mental status combined with a high fever can indicate a life-threatening situation. Choices A, C, and D present important conditions that require medical care, but they are not as urgent as the 19-year-old with a high fever and confusion. The 12-year-old with a laceration may require treatment for bleeding and a tetanus shot, the 49-year-old with a compound fracture needs urgent orthopedic intervention, and the 65-year-old with a high blood sugar is concerning for hyperglycemia but can wait momentarily compared to the client with a fever and altered mental status.

4. 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.

5. What are the key nursing assessments for a patient receiving enteral feeding?

• A. Monitor gastric residual volume and check for abdominal distension
• B. Ensure the correct placement of the feeding tube
• C. Assess for signs of dehydration and electrolyte imbalances
• D. Elevate the head of the bed to prevent aspiration

Correct answer: A

Rationale: The correct answer is A: Monitor gastric residual volume and check for abdominal distension. These assessments are critical to evaluate the patient's tolerance to enteral feeding. Monitoring gastric residual volume helps determine gastric emptying, while checking for abdominal distension can identify complications like bowel obstruction. Choices B, C, and D are important aspects of enteral feeding care but are not the primary assessments. Ensuring the correct placement of the feeding tube is crucial for safety, assessing for signs of dehydration and electrolyte imbalances is essential for overall patient well-being, and elevating the head of the bed is vital to prevent aspiration. However, these are not the key assessments specifically related to enteral feeding.

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