Nursing Elites

1. What is the best method to manage fluid overload in a patient with heart failure?

• A. Administer diuretics
• B. Provide oral fluids
• C. Increase fluid intake
• D. Provide chest physiotherapy

Correct answer: A

Rationale: Administering diuretics is the best method to manage fluid overload in a patient with heart failure. Diuretics help to remove excess fluid from the body by increasing urine output, thus reducing the fluid volume in the bloodstream and tissues. Providing oral fluids (choice B) or increasing fluid intake (choice C) would exacerbate the fluid overload rather than managing it. Chest physiotherapy (choice D) is not indicated for managing fluid overload in heart failure; it is more commonly used for conditions affecting the lungs or airways.

2. A client is receiving chemotherapy and is being taught about preventing infection. Which of the following instructions should the nurse include?

• A. Take your temperature daily.
• B. Avoid fresh fruits and vegetables.
• C. Limit your intake of high-protein foods.
• D. Increase your intake of high-fat foods.

Correct answer: B

Rationale: Clients receiving chemotherapy are instructed to avoid fresh fruits and vegetables to lower the risk of infection. Fresh produce may harbor bacteria or other pathogens that could be harmful to individuals with compromised immune systems. Taking the temperature daily may be important but is not directly related to preventing infection. Limiting high-protein foods is not necessary unless there are specific dietary restrictions due to the treatment plan. Increasing the intake of high-fat foods is not recommended during chemotherapy as a high-fat diet may lead to other health issues.

3. A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory values should the nurse monitor?

• A. Prothrombin time (PT)
• B. Hemoglobin
• C. aPTT
• D. INR

Correct answer: D

Rationale: The correct answer is D, INR. The International Normalized Ratio (INR) is used to monitor the therapeutic effect of warfarin and to adjust the dose as needed. While Prothrombin time (PT) and activated Partial Thromboplastin Time (aPTT) are also related to coagulation studies, monitoring INR specifically helps in managing warfarin therapy. Hemoglobin, on the other hand, is not typically monitored in relation to warfarin therapy.

4. A nurse is assessing a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?

• A. Heart rate 110/min.
• B. Temperature of 37.4°C (99.3°F).
• C. Respiratory rate of 18/min.
• D. Urine output of 20 mL/hr.

Correct answer: D

Rationale: A urine output of 20 mL/hr is below the expected range and indicates potential renal failure, requiring immediate intervention. In postoperative patients, a urine output less than 30 mL/hr suggests inadequate renal perfusion, a concern that needs prompt attention to prevent renal complications. The heart rate of 110/min, temperature of 37.4°C (99.3°F), and respiratory rate of 18/min are within normal ranges for a postoperative client and do not indicate immediate issues.

5. A client has thrombocytopenia. What action should the nurse include?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct action for the nurse when caring for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is characterized by a low platelet count, leading to increased bleeding tendencies. Providing a stool softener helps prevent constipation, reducing the likelihood of straining during bowel movements and subsequent bleeding. Encouraging the client to floss daily (choice A) is unrelated to managing thrombocytopenia. Removing fresh flowers from the client's room (choice B) pertains more to infection control than addressing thrombocytopenia. Avoiding serving raw vegetables (choice D) is not directly associated with managing thrombocytopenia symptoms.

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