Nursing Elites

1. The nurse is providing care for a client with advanced liver disease who is experiencing ascites. Which intervention should the nurse implement to help manage the client's fluid volume?

• A. Increase the client's sodium intake
• B. Encourage the client to drink more fluids
• C. Place the client in a supine position
• D. Administer a diuretic as prescribed

Correct answer: D

Rationale: Administering a diuretic as prescribed is the most appropriate intervention to manage fluid volume in a client with ascites due to advanced liver disease. Diuretics help reduce fluid accumulation in the body, including the abdominal cavity where ascites occurs. Increasing sodium intake would worsen fluid retention, and encouraging more fluid intake can exacerbate ascites. Placing the client in a supine position does not directly address the fluid volume issue associated with ascites.

2. The nurse is administering a new medication to a client. What is the priority action before administering the drug?

• A. Verify the client's allergies
• B. Check the client's blood pressure
• C. Assess the client's pain level
• D. Provide client education on the medication

Correct answer: A

Rationale: Verifying the client's allergies is the priority action before administering any medication. It is crucial to identify any known allergies to prevent potential allergic reactions, which can be severe and life-threatening. Checking the client's blood pressure, assessing pain levels, and providing education on the medication are important aspects of client care but verifying allergies is essential for ensuring the safety of the client.

3. A client with a tracheostomy develops copious, thick secretions. What is the nurse's priority action?

• A. Increase the client's fluid intake.
• B. Perform tracheal suctioning.
• C. Administer a mucolytic agent.
• D. Increase the humidity of the oxygen source.

Correct answer: D

Rationale: The correct answer is to increase the humidity of the oxygen source. This action helps thin thick secretions, making them easier to clear from the tracheostomy tube. Increasing fluid intake (Choice A) can be beneficial in some cases but addressing humidity is more specific to managing thick secretions in a client with a tracheostomy. Tracheal suctioning (Choice B) should be done after attempting to thin the secretions with increased humidity. Administering a mucolytic agent (Choice C) is a possible intervention but typically comes after addressing humidity and before resorting to suctioning to avoid unnecessary invasiveness.

4. A client receiving chemotherapy for cancer treatment is experiencing nausea and vomiting. What is the nurse's best intervention to manage these symptoms?

• A. Offer frequent, small meals
• B. Administer antiemetics before meals
• C. Encourage the client to eat a high-fat diet
• D. Provide the client with cold, carbonated beverages

Correct answer: B

Rationale: Administering antiemetics before meals is the best intervention to manage nausea and vomiting in clients receiving chemotherapy. This proactive approach helps control symptoms by preventing nausea from occurring, rather than waiting to treat it once symptoms have already started. Offering frequent, small meals (choice A) may worsen symptoms in some cases due to increased stomach activity. Encouraging a high-fat diet (choice C) can be difficult for nauseated clients and may not alleviate symptoms. Providing cold, carbonated beverages (choice D) could exacerbate nausea further due to the temperature and carbonation.

5. A client with COPD and a history of emphysema presents with increasing shortness of breath. What action should the nurse implement first?

• A. Notify the healthcare provider of the client's distress.
• B. Auscultate the client's lung sounds and oxygen saturation.
• C. Determine if the client is experiencing anxiety.
• D. Assess the oxygen delivery system.

Correct answer: B

Rationale: The correct action for the nurse to implement first is to auscultate the client's lung sounds and oxygen saturation. This helps in assessing the respiratory status of the client, which is crucial in managing COPD and emphysema exacerbations. Checking for any abnormalities in lung sounds and monitoring oxygen saturation levels can provide important information for immediate intervention. Option A is not the first action to take in this situation as directly assessing the client's respiratory status is more immediate. Option C, determining if the client is experiencing anxiety, is important but should come after assessing the physical respiratory status. Option D, assessing the oxygen delivery system, is also essential but should follow the direct assessment of the client's respiratory status.

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