Nursing Elites

1. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?

• A. Monitor vital signs every two (2) hours until stable
• B. Weigh the client in the same clothing at the same time daily
• C. Administer mouth care every eight (8) hours
• D. A, B, and C

Correct answer: D

Rationale: The correct interventions to include in the plan of care for a client with fluid volume deficit are monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. These interventions are crucial for managing and detecting fluid volume changes. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and does not address the key aspects of monitoring and assessing fluid status, making it an incorrect choice.

2. The nurse is teaching the client diagnosed with Type 2 diabetes mellitus about diet. Which diet selection indicates the client understands the teaching?

• A. A submarine sandwich, potato chips, and diet cola
• B. Four (4) slices of a supreme thin-crust pizza and milk
• C. Smoked turkey sandwich, celery sticks, and unsweetened tea
• D. A roast beef sandwich, fried onion rings, and a cola

Correct answer: C

Rationale: The correct answer is C because a smoked turkey sandwich with celery sticks and unsweetened tea is a healthier option for someone with Type 2 diabetes mellitus. Turkey is a lean protein source, celery sticks are low in calories and carbs, and unsweetened tea is a better choice than sugary beverages. Choices A, B, and D are incorrect. Choice A includes high-carb and high-sugar items like potato chips and diet cola, which are not ideal for diabetes management. Choice B contains a high-carb pizza and milk, which may not be suitable for controlling blood sugar levels. Choice D includes fried onion rings and cola, which are high in unhealthy fats and sugars, making it a poor choice for a diabetic diet.

3. The nurse is teaching the client with peripheral vascular disease. Which intervention should the nurse discuss with the client?

• A. Keep the area between the toes dry.
• B. Wear comfortable, well-fitting shoes.
• C. Cut toenails straight across.
• D. A,B

Correct answer: D

Rationale: The correct interventions for a client with peripheral vascular disease include keeping the area between the toes dry to prevent moisture-related skin issues and wearing comfortable, well-fitting shoes to prevent injury and promote circulation. Cutting toenails straight across is important to prevent ingrown toenails, but in this case, an arch cut can lead to injury. Therefore, choices A and B are correct, making option D the most appropriate answer. Choice C is incorrect in this context.

4. Which of the following drugs contribute to peptic ulcers?

• A. Antacids
• B. Certain antibiotics
• C. Cholesterol-lowering medications
• D. Nonsteroidal anti-inflammatory drugs

Correct answer: D

Rationale: The correct answer is D: Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are known to contribute to peptic ulcers by affecting the gastric mucosa. Choice A, Antacids, actually help to alleviate symptoms of peptic ulcers by neutralizing stomach acid. Choice B, Certain antibiotics, are used to treat H. pylori infections, a common cause of peptic ulcers. Choice C, Cholesterol-lowering medications, do not contribute to peptic ulcers.

5. The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:

• A. Provide nutrients
• B. Increase protein stores
• C. Elevate the circulating blood volume
• D. Divert blood flow away from the liver temporarily

Correct answer: C

Rationale: The correct answer is C: Elevate the circulating blood volume. Salt-poor albumin is given to increase the circulating blood volume, which helps reduce ascites by improving fluid distribution within the body. Choices A, B, and D are incorrect because salt-poor albumin is not administered to provide nutrients, increase protein stores, or divert blood flow away from the liver.

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