Nursing Elites

1. Which intervention is essential when caring for a client with heart failure on fluid restriction?

• A. Encourage the client to drink water throughout the day
• B. Monitor the client's weight daily to assess fluid balance
• C. Limit fluid intake during meals
• D. Weigh the client once a week to assess fluid balance

Correct answer: B

Rationale: The correct answer is B: 'Monitor the client's weight daily to assess fluid balance.' When caring for a client with heart failure on fluid restriction, it is essential to monitor their weight daily to evaluate fluid balance accurately. This helps healthcare providers assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink water throughout the day contradicts fluid restriction. Limiting fluid intake during meals may not provide a comprehensive assessment of fluid balance, and weighing the client once a week is not frequent enough to detect rapid changes in fluid status that could worsen heart failure symptoms.

2. What is the best dietary recommendation for a patient with chronic kidney disease?

• A. Low-protein diet
• B. High-protein diet
• C. Low-sodium diet
• D. High-sodium diet

Correct answer: A

Rationale: The correct answer is a low-protein diet for a patient with chronic kidney disease. In chronic kidney disease, the kidneys may have difficulty filtering waste products from protein metabolism, leading to a buildup of toxins in the body. Therefore, reducing protein intake can help lessen the workload on the kidneys. Choices B, C, and D are incorrect. A high-protein diet would increase the workload on the kidneys, while a low-sodium diet is beneficial for conditions like hypertension or heart failure but not specifically targeted for chronic kidney disease. A high-sodium diet can worsen fluid retention and hypertension in patients with kidney disease.

3. Which nursing intervention is essential for a client diagnosed with heart failure?

• A. Encourage fluid intake to prevent dehydration
• B. Monitor the client's weight daily to assess fluid balance
• C. Increase sodium intake to prevent fluid retention
• D. Limit fluid intake to avoid overload

Correct answer: B

Rationale: The correct answer is to monitor the client's weight daily to assess fluid balance in clients with heart failure. This intervention helps healthcare providers evaluate fluid retention or loss, which is crucial in managing heart failure. Choice A is incorrect because excessive fluid intake can worsen heart failure symptoms by causing fluid overload. Choice C is incorrect because increasing sodium intake can lead to fluid retention, exacerbating heart failure. Choice D is incorrect as limiting fluid intake excessively can also be harmful in heart failure management, potentially leading to dehydration.

4. A client takes prednisone daily for the treatment of chronic asthma. The nurse should plan to monitor the client for which of the following adverse effects?

• A. Hyperglycemia
• B. Hypertension
• C. Gastric ulcer formation
• D. Diarrhea

Correct answer: C

Rationale: The correct answer is C: Gastric ulcer formation. Prednisone, a corticosteroid, increases the risk of gastric ulcer formation, especially with long-term use. While prednisone can also lead to hyperglycemia (choice A) and hypertension (choice B) as adverse effects, monitoring for gastric ulcer formation is a priority due to its association with corticosteroid therapy. Diarrhea (choice D) is not a common adverse effect of prednisone and is less likely compared to gastric ulcers.

5. Which of the following actions should the nurse take for a client who has been diagnosed with dementia and is at risk for falls?

• A. Maintain the client's bed in the lowest position
• B. Use a bed exit alarm system
• C. Assist the client with ambulation every hour
• D. Raise all 4 side rails for safety

Correct answer: B

Rationale: The correct answer is B: "Use a bed exit alarm system." For a client with dementia at risk for falls, a bed exit alarm system is beneficial as it alerts staff when the client is trying to get up, helping to reduce fall risks. Choice A, maintaining the client's bed in the lowest position, may not prevent falls as effectively as an alarm system. Choice C, assisting the client with ambulation every hour, may not be feasible and could disrupt the client's rest. Choice D, raising all 4 side rails for safety, can lead to restraint issues and is not recommended as a routine fall prevention measure.

Similar Questions