Nursing Elites

1. The client with a diagnosis of chronic heart failure is receiving discharge teaching. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself every day at the same time.
• B. I will call my doctor if my legs swell more.
• C. I will take my water pill only when I feel short of breath.
• D. I will limit the amount of salt in my diet.

Correct answer: C

Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to help manage fluid retention in chronic heart failure. This statement indicates a need for further teaching as the client needs to understand the importance of consistent medication adherence. Choices A, B, and D demonstrate good understanding of self-care management in heart failure, including daily weight monitoring, prompt reporting of worsening symptoms to the healthcare provider, and dietary sodium restriction, respectively.

2. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

• A. 2 cups of soup
• B. 1 quart of water
• C. 8 oz of ice chips
• D. 6 oz of tea

Correct answer: C

Rationale: The correct answer is C: 8 oz of ice chips. When calculating fluid intake, the nurse should document half of the volume of ice chips to account for the air in between the chips. Therefore, 8 oz of ice chips equals 120 mL of fluid. Choices A, B, and D are incorrect because they do not equate to 120 mL of fluid intake as per the given scenario. Choice A, 2 cups of soup, is more than 120 mL. Choice B, 1 quart of water, is significantly more than 120 mL. Choice D, 6 oz of tea, is less than 120 mL.

3. A nurse is planning strategies to manage time effectively for client care. What should the nurse implement?

• A. Use the planning step of the nursing process to prioritize client care delivery.
• B. Delegate all tasks to assistive personnel.
• C. Focus on completing tasks in the order they are assigned.
• D. Avoid using a checklist for daily tasks.

Correct answer: A

Rationale: The correct answer is A. Using the planning step of the nursing process to prioritize client care delivery is crucial for effective time management. By prioritizing tasks based on client needs and acuity levels, the nurse can ensure that the most critical care is provided in a timely manner. Choice B is incorrect because while delegation is important, not all tasks can be delegated, and the nurse is ultimately responsible for the care provided. Choice C is incorrect as completing tasks in the order they are assigned may not align with the urgency of client needs. Choice D is incorrect as using a checklist can help the nurse stay organized and ensure that all necessary tasks are completed.

4. What advice should the client be given if they are feeling dizzy upon standing after taking a diuretic for hypertension?

• A. Avoid standing up too quickly.
• B. Increase fluid intake to stay hydrated.
• C. Eat more salt to help retain fluids.
• D. Wear compression stockings during the day.

Correct answer: A

Rationale: The correct advice for a client feeling dizzy upon standing after taking a diuretic for hypertension is to avoid standing up too quickly. Diuretics can lead to orthostatic hypotension, causing dizziness upon sudden position changes. Increasing fluid intake can exacerbate the issue by further lowering blood pressure. Eating more salt might counteract the diuretic's effects but is not the primary intervention for orthostatic hypotension. Compression stockings are more relevant for venous insufficiency than for orthostatic hypotension.

5. The healthcare provider is caring for a patient who has multiple ticks on lower legs and body. What should the healthcare provider do to rid the patient of ticks?

• A. Use blunt tweezers and pull upward with steady pressure.
• B. Burn the ticks with a match or a small lighter.
• C. Allow the ticks to drop off by themselves.
• D. Apply miconazole and cover with plastic.

Correct answer: A

Rationale: Correct answer: When removing ticks, it is essential to use blunt tweezers to grasp the tick as close to the head as possible and pull upward with even, steady pressure to remove the entire tick. Option B is incorrect because burning ticks can increase the risk of infection and is not recommended. Option C is incorrect as waiting for ticks to drop off by themselves prolongs potential exposure to tick-borne diseases. Option D is incorrect as miconazole is an antifungal medication and not used for tick removal.

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