Nursing Elites

1. Which intervention should be included for a client with heart failure?

• A. Encourage increased fluid intake
• B. Weigh the client daily to monitor fluid balance
• C. Restrict fluid intake during meals
• D. Limit daily activity to prevent fatigue

Correct answer: B

Rationale: Weighing the client daily to monitor fluid balance is crucial for clients with heart failure. This intervention helps assess for fluid retention or depletion, providing valuable information for managing the condition effectively. Encouraging increased fluid intake (Choice A) is contraindicated in heart failure as it can worsen fluid overload. Restricting fluid intake during meals (Choice C) may lead to dehydration, which is harmful for clients with heart failure. Limiting daily activity (Choice D) is not recommended as appropriate activity levels should be encouraged for overall well-being, under guidance to prevent excessive fatigue.

2. What are the signs of hypoglycemia, and how should they be managed?

• A. Sweating, trembling; administer glucose
• B. Headache, confusion; administer insulin
• C. Dizziness, fatigue; administer glucose
• D. Increased heart rate; provide a high-sugar snack

Correct answer: A

Rationale: The correct signs of hypoglycemia are sweating and trembling. These should be managed by administering glucose to raise blood sugar levels. Headache, confusion, dizziness, fatigue, or increased heart rate are not typical signs of hypoglycemia. Administering insulin in response to hypoglycemia would further lower blood sugar levels, exacerbating the condition.

3. A nurse is caring for a client with an NG tube who is experiencing nausea and decreased gastric secretions. What is the priority nursing action?

• A. Increase the suction pressure
• B. Turn the client onto their side
• C. Irrigate the NG tube with sterile water
• D. Replace the NG tube with a new one

Correct answer: D

Rationale: The correct answer is to replace the NG tube with a new one. When a client with an NG tube experiences nausea and decreased gastric secretions, it indicates a possible problem with the tube itself. Replacing the tube ensures proper functioning and can alleviate the symptoms. Increasing the suction pressure (Choice A) can worsen the client's condition. Turning the client onto their side (Choice B) may be helpful in some situations but does not address the underlying issue. Irrigating the NG tube with sterile water (Choice C) is not the priority and may not resolve the problem.

4. A client is having difficulty voiding after removal of an indwelling urinary catheter. What should the nurse do?

• A. Assess for bladder distention after 6 hours
• B. Encourage the client to use a bedpan in the supine position
• C. Restrict the client's intake of oral fluids
• D. Pour warm water over the client's perineum

Correct answer: D

Rationale: The correct answer is to pour warm water over the client's perineum. This action helps stimulate voiding post-catheterization by promoting relaxation and providing sensory input. Assessing for bladder distention after 6 hours (Choice A) is important but not the immediate intervention needed for difficulty voiding. Encouraging the client to use a bedpan in the supine position (Choice B) may not effectively address the issue of post-catheterization voiding difficulty. Restricting the client's intake of oral fluids (Choice C) is not appropriate and can lead to dehydration, which is not helpful in promoting voiding.

5. A client is concerned about extreme fatigue after an acute myocardial infarction. What is the best strategy the nurse can suggest to promote independence in self-care?

• A. Encourage the client to rest and let the healthcare team take over self-care tasks
• B. Instruct the client to gradually resume self-care tasks, with rest periods
• C. Assign assistive personnel to complete self-care tasks for the client
• D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: The best strategy to promote independence in self-care for a client concerned about extreme fatigue after an acute myocardial infarction is to instruct the client to gradually resume self-care tasks, with rest periods. This approach allows the client to regain independence without overexerting. Choice A is incorrect because encouraging the client to rest completely and letting the healthcare team take over self-care tasks may hinder independence. Choice C is incorrect as assigning assistive personnel to complete self-care tasks does not promote the client's independence. Choice D is not the best option as the primary focus should be on empowering the client to perform self-care tasks independently.

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