Nursing Elites

1. What intervention is most important to teach the client about identifying the onset of dehydration?

• A. Measuring abdominal girth
• B. Converting ounces to milliliters
• C. Obtaining and charting daily weight
• D. Selecting food items with high water content

Correct answer: C

Rationale: The correct answer is C: Obtaining and charting daily weight. Monitoring daily weight is crucial in identifying the onset of dehydration as weight loss can be an early sign. Measuring abdominal girth (choice A) is not the most reliable method for detecting dehydration. Converting ounces to milliliters (choice B) and selecting food items with high water content (choice D) may be important for overall hydration but are not the most critical interventions for identifying the onset of dehydration.

2. The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?

• A. Document the observation in the chart.
• B. Measure urine specific gravity and volume.
• C. Assess the pulse and blood pressure.
• D. Assess the client's deep tendon reflexes.

Correct answer: C

Rationale: The correct answer is to assess the pulse and blood pressure. Distended neck veins can indicate fluid volume overload or heart failure, which can lead to hemodynamic instability. Assessing the pulse and blood pressure will provide immediate information on the client's cardiovascular status. Documenting the observation in the chart (choice A) is important but not the priority when immediate assessment is needed. Measuring urine specific gravity and volume (choice B) is important for assessing renal function but is not the priority in this situation. Assessing the client's deep tendon reflexes (choice D) is not relevant to addressing distended neck veins in a client sitting to eat.

3. The healthcare professional is assessing a client with hypertension. Which client outcome is indicative of effective hypertension management?

• A. Absence of pedal edema in the lower legs.
• B. Absence of complaints of sexual dysfunction.
• C. No indication of renal impairment.
• D. Blood pressure reading of 148/94 mm Hg.

Correct answer: C

Rationale: The correct answer is 'No indication of renal impairment.' Effective hypertension management aims to prevent complications such as renal impairment. Checking for signs of kidney issues, like abnormal renal function tests, is crucial in monitoring the client's condition. Choices A, B, and D are not specific indicators of effective hypertension management. Pedal edema, sexual dysfunction, and a single blood pressure reading are important but do not solely determine the effectiveness of managing hypertension.

4. The nurse is caring for a client who has had surgery the previous day. The client tells the nurse, "Breathing in using this thing (incentive spirometer) is a ridiculous waste of time."? What is the nurse's best response?

• A. "The spirometer will help you cough effectively."?
• B. "The spirometer will help your lungs expand."?
• C. "The spirometer will help prevent blood clots."?
• D. "The spirometer will improve blood flow in your lungs."?

Correct answer: B

Rationale: The correct answer is, '"The spirometer will help your lungs expand."?' Incentive spirometry is used postoperatively to help prevent atelectasis by expanding the lungs and improving lung function. Choice A is incorrect because the primary purpose of the spirometer is not to help cough effectively. Choice C is incorrect because while deep breathing with the spirometer can indirectly help prevent blood clots by improving lung function, its primary purpose is not to prevent blood clots directly. Choice D is incorrect because although using the spirometer can improve ventilation and oxygenation, its main purpose is not to improve blood flow in the lungs.

5. When obtaining a client’s vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse’s best intervention?

• A. Call the healthcare provider and report the finding.
• B. Reassess the client’s blood pressure at the next follow-up appointment.
• C. Administer an additional antihypertensive medication to the client.
• D. Teach the client lifestyle modifications to decrease blood pressure.

Correct answer: D

Rationale: The correct answer is to teach the client lifestyle modifications to decrease blood pressure. A blood pressure reading of 134/88 mm Hg falls within the prehypertension range. The initial approach to managing prehypertension involves lifestyle modifications such as dietary changes, exercise, and stress reduction techniques. Calling the healthcare provider without attempting non-pharmacological interventions first is premature. Reassessing blood pressure at the next follow-up appointment may delay necessary interventions. Administering additional antihypertensive medication is not indicated at this stage as lifestyle modifications are the first line of treatment for prehypertension.

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