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. A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child?

• A. Flushing
• B. Dyspnea
• C. Tachycardia
• D. Hypotension

Correct answer: C

Rationale: The correct answer is C, Tachycardia. Albuterol, a bronchodilator used to treat asthma, commonly causes tachycardia as a side effect. This occurs due to the medication's stimulatory effect on beta-2 adrenergic receptors. Flushing (Choice A) is not a common side effect of albuterol. Dyspnea (Choice B) refers to difficulty breathing, which is a symptom albuterol aims to alleviate. Hypotension (Choice D) is not typically associated with albuterol use; instead, albuterol can lead to an increase in blood pressure.

3. What type of food should a patient taking anticoagulants be cautious about consuming?

• A. High-protein foods
• B. High-fiber foods
• C. High-vitamin K foods
• D. High-calcium foods

Correct answer: C

Rationale: Patients taking anticoagulants should be cautious about consuming high-vitamin K foods. Vitamin K can interfere with the effectiveness of anticoagulants by affecting blood clotting. Choices A, B, and D are incorrect because they do not directly interact with the action of anticoagulants.

4. Which situation(s) are classified as natural disasters?

• A. Blizzards
• B. Blizzards, Volcanic eruptions
• C. Volcanic eruptions
• D. Structural collapse

Correct answer: B

Rationale: Blizzards and volcanic eruptions are classified as natural disasters because they are caused by natural forces beyond human control. In contrast, structural collapses are typically a result of man-made factors, making them not classified as natural disasters. Therefore, the correct answer is B.

5. What is the primary goal of care for a client diagnosed with sickle cell anemia?

• A. The client will call the healthcare provider if feeling ill.
• B. The client will be compliant with the medical regimen.
• C. The client will live as normal a life as possible.
• D. The client will verbalize understanding of treatments.

Correct answer: C

Rationale: The correct answer is C: 'The client will live as normal a life as possible.' For a client with sickle cell anemia, the primary goal of care is to promote a good quality of life by managing symptoms, preventing crises, and enhancing overall well-being. Option A is incorrect as it focuses on a specific action rather than the overall goal of care. Option B is important but not the primary goal; compliance is a means to achieve better health outcomes. Option D is also important but does not address the holistic approach of helping the client maintain a normal lifestyle despite their condition.

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