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 teaching point for a client with left-leg weakness learning to use a cane?

• A. Use the cane on the weaker side
• B. Maintain two points of support on the floor at all times
• C. Advance the cane 30 to 45 cm with each step
• D. Advance the cane and the strong leg together

Correct answer: B

Rationale: The correct teaching point for a client with left-leg weakness learning to use a cane is to maintain two points of support on the floor at all times. This ensures better stability and support for the client while walking. Choice A is incorrect because the cane should be used on the stronger side to support the weaker leg. Choice C is incorrect as advancing the cane too far with each step may compromise balance. Choice D is incorrect because advancing the cane and the strong leg together may not provide adequate support for the weaker leg.

3. What are the key components of a focused respiratory assessment, and how do you recognize signs of respiratory distress?

• A. Inspection, Palpation, Percussion, Auscultation
• B. Palpation, Inspection, Observation, Auscultation
• C. Percussion, Inspection, Auscultation, Palpation
• D. Inspection, Percussion, Auscultation, Palpation

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment should start with inspection (observing the breathing pattern), followed by palpation (feeling for abnormalities like crepitus), percussion (evaluating for dullness or hyperresonance), and auscultation (listening to lung sounds). This systematic approach helps to identify signs of respiratory distress, such as abnormal breath sounds, increased respiratory rate, use of accessory muscles, and cyanosis. Choices B, C, and D are incorrect because they do not follow the standard order and sequence of a focused respiratory assessment.

4. A client undergoing radiation therapy is being taught about skin care by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will use a heating pad to soothe the skin
• B. I will avoid using perfumed lotions on the treated area
• C. I will apply cold compresses to the area
• D. I will scrub the area daily with soap and water

Correct answer: B

Rationale: The correct answer is B because avoiding perfumed lotions is important to prevent skin irritation after radiation therapy. Using a heating pad (A) can further damage the skin, applying cold compresses (C) may not be recommended, and scrubbing the area daily with soap and water (D) can be too harsh on the skin, leading to further irritation and damage.

5. What are the key components of a respiratory assessment?

• A. Inspection, Palpation, Percussion, Auscultation
• B. Inspection, Observation, Auscultation, Percussion
• C. Auscultation, Palpation, Observation, Percussion
• D. Observation, Palpation, Percussion, Auscultation

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment involves inspecting the chest for symmetry and signs of distress, palpating for tenderness or abnormal masses, performing percussion to assess underlying tissues, and auscultating lung sounds. Choice B is incorrect as observation is a broad term that can encompass both inspection and palpation. Choice C is incorrect as auscultation is usually performed after inspection and palpation. Choice D is incorrect as observation should be more specific, and auscultation is a key component that is typically done last in a respiratory assessment.

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