Nursing Elites

1. Fluids are restricted to 1500 ml/day for a male client with AKI. He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. What intervention should the nurse implement?

• A. Remove all sources of liquids from the client's room
• B. Allow family to give the client a measured amount of ice chips
• C. Restrict family visiting until the client's condition is stable
• D. Provide the client with oral swabs to moisten his mouth

Correct answer: D

Rationale: In this scenario, the nurse should provide the client with oral swabs to moisten his mouth. This intervention helps alleviate the client's thirst without increasing fluid intake, which is essential in managing AKI. Removing all sources of liquids from the client's room (Choice A) may not address the underlying issue of thirst and could lead to increased frustration. Allowing the family to give the client ice chips (Choice B) would add to the client's fluid intake, contradicting the restriction. Restricting family visiting (Choice C) is not necessary and does not directly address the client's thirst.

2. The client with osteoporosis is being taught about dietary modifications by the nurse. Which food should the nurse recommend to increase calcium intake?

• A. Broccoli
• B. Chicken breast
• C. White bread
• D. Apple

Correct answer: A

Rationale: Broccoli is the correct answer as it is a good source of calcium, which is essential for clients with osteoporosis. Broccoli is a green leafy vegetable that provides a significant amount of calcium. Chicken breast, white bread, and apple do not contain as much calcium as broccoli and therefore are not the best choices to recommend for increasing calcium intake in clients with osteoporosis.

3. A client with a spinal cord injury at the level of T1 is at risk for autonomic dysreflexia. Which symptom is indicative of this condition?

• A. Hypotension
• B. Tachycardia
• C. Severe headache
• D. Flushed skin below the level of injury

Correct answer: C

Rationale: Corrected Rationale: Autonomic dysreflexia is a condition commonly seen in clients with spinal cord injuries at T6 or above. It is characterized by a sudden onset of severe hypertension, pounding headache, profuse sweating, nasal congestion, and flushing of the skin above the level of injury. The severe headache is a key symptom resulting from uncontrolled hypertension. Choices A, B, and D are incorrect as autonomic dysreflexia typically presents with hypertension, not hypotension, tachycardia, or flushed skin below the level of injury.

4. An older adult with chronic obstructive pulmonary disease (COPD) was recently admitted to the hospital with heart failure (HF). Which actions should the nurse take in providing care? (Select all that apply)

• A. Monitor electrolyte levels.
• B. Maintain pulse oximetry.
• C. Provide assistance with mobility.
• D. All of the Above

Correct answer: D

Rationale: In a patient with COPD and HF, monitoring electrolyte levels is essential due to potential imbalances caused by medications or fluid shifts. Maintaining pulse oximetry is crucial to assess oxygenation status in COPD and HF. Providing assistance with mobility helps prevent deconditioning and complications. Therefore, all the actions mentioned are necessary for comprehensive care in this scenario, making option D the correct answer. Choices A, B, and C are all important aspects of managing COPD and HF, ensuring holistic and effective care.

5. A client with Parkinson's disease is experiencing difficulty swallowing. Which intervention should the nurse implement to prevent aspiration?

• A. Encourage the client to eat quickly.
• B. Provide a straw for liquids.
• C. Place the client in an upright position during meals.
• D. Offer thin liquids.

Correct answer: C

Rationale: Placing the client in an upright position during meals is the correct intervention to prevent aspiration in a client with Parkinson's disease. This position helps facilitate swallowing and reduces the risk of aspiration. Choice A is incorrect because encouraging the client to eat quickly can increase the risk of choking and aspiration. Choice B is not the best option as straws may not prevent aspiration effectively. Choice D is incorrect as thin liquids can actually increase the risk of aspiration in individuals with swallowing difficulties.

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