Nursing Elites

1. The healthcare provider is caring for a client who is experiencing fluid volume deficit (dehydration). Which intervention should the healthcare provider implement to assess the effectiveness of fluid replacement therapy?

• A. Monitor daily weights
• B. Assess skin turgor
• C. Evaluate blood pressure trends
• D. Check urine specific gravity

Correct answer: A

Rationale: Monitoring daily weights is an accurate method to assess the effectiveness of fluid replacement therapy because changes in weight reflect changes in fluid balance. Fluid volume deficit can be objectively evaluated by monitoring daily weights as it provides a more precise measurement of fluid status over time. Assessing skin turgor (choice B) is subjective and may not provide as accurate or measurable data as monitoring daily weights. Evaluating blood pressure trends (choice C) can give information about circulatory status but may not directly reflect fluid volume status. Checking urine specific gravity (choice D) can indicate the concentration of urine but does not provide a comprehensive assessment of overall fluid balance like monitoring daily weights does.

2. The healthcare provider is caring for a client diagnosed with type 2 diabetes mellitus. Which intervention should the healthcare provider implement to assess the client’s glycemic control?

• A. Monitor fasting blood glucose levels
• B. Check urine for ketones
• C. Evaluate hemoglobin A1c levels
• D. Assess the client’s dietary intake

Correct answer: C

Rationale: Evaluating hemoglobin A1c levels is the most appropriate intervention to assess glycemic control in a client with type 2 diabetes mellitus. Hemoglobin A1c levels reflect the average blood glucose control over the past 2-3 months, providing valuable information for monitoring and managing diabetes. Monitoring fasting blood glucose levels (Choice A) is important for daily management but does not provide a long-term view like hemoglobin A1c. Checking urine for ketones (Choice B) is more relevant for assessing diabetic ketoacidosis. Assessing dietary intake (Choice D) is crucial for overall diabetes management but does not directly assess glycemic control.

3. After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly expressing a dislike for all healthcare providers and nurses. How should the nurse respond?

• A. Ask the client to remain quiet so the procedure can be performed safely.
• B. Concentrate on completing the insertion as efficiently as possible.
• C. Calmly reassure the client that the discomfort will be temporary.
• D. Tell the client a joke as a means of distraction from the procedure.

Correct answer: C

Rationale: In this situation, the nurse should respond by calmly reassuring the client that the discomfort from the IV insertion will be temporary. By providing reassurance and addressing the client's concerns, the nurse can help reduce the client's apprehension and create a more supportive environment for the procedure.

4. A client is admitted with a diagnosis of heart failure. Which dietary instruction should the nurse provide?

• A. Increase fluid intake to 3 liters per day.
• B. Limit sodium intake to 2 grams per day.
• C. Avoid foods high in potassium.
• D. Increase protein intake to promote healing.

Correct answer: B

Rationale: Limiting sodium intake to 2 grams per day (B) is a crucial dietary instruction for clients with heart failure. It helps manage fluid retention and reduces the workload on the heart. Excessive sodium can lead to fluid retention, worsening heart failure symptoms. Increasing fluid intake (A) can further exacerbate fluid overload in heart failure patients. Avoiding foods high in potassium (C) is not necessary unless the client has hyperkalemia; in heart failure, potassium restriction is not a primary dietary concern. Increasing protein intake (D) is not the priority for heart failure management; focusing on sodium restriction is more beneficial.

5. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?

• A. The occurrence of any episodes of sleep apnea
• B. The child's blood pressure, pulse, and respirations
• C. Length of rapid eye movement (REM) sleep that the child is experiencing
• D. Description of the family's home environment

Correct answer: D

Rationale: In response to the mother's report, the nurse should assess the family's home environment first to identify any factors that may hinder the establishment of bedtime routines conducive to sleep. Factors such as noise, light, distractions, or other environmental aspects could be contributing to the child's difficulty falling asleep at a reasonable hour and waking up in the morning.

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