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. A nurse is caring for a client who is scheduled for a bronchoscopy. Which of the following findings should the nurse report to the provider?

• A. The client is anxious about the procedure.
• B. The client has not eaten for 8 hours.
• C. The client has a reported allergy to shellfish.
• D. The client has a platelet count of 100,000/mm³.

Correct answer: D

Rationale: The correct answer is D. A platelet count of 100,000/mm³ is low and increases the risk of bleeding during the bronchoscopy. This finding should be reported to the provider for further evaluation and possible intervention. Choices A, B, and C are not as critical in this situation. Anxiety about the procedure is common and can be managed with appropriate interventions. Not eating for 8 hours is a standard pre-procedure requirement to prevent aspiration during sedation. A reported allergy to shellfish is important to note but is not directly related to the risk of complications during a bronchoscopy.

3. What is the correct procedure for taking a telephone order from a provider?

• A. State patient name, drug, dose, route, frequency, and read back the order
• B. State the medication and ask for a witness to listen to the order
• C. Write down the order and verify with the provider within 12 hours
• D. Have the provider verify the order during the next in-person visit

Correct answer: A

Rationale: The correct procedure for taking a telephone order from a provider is to state the patient's name, drug, dose, route, frequency, and then read back the order to ensure accuracy. This process helps in preventing errors and ensures that all relevant information is correctly documented. Choice B is incorrect because having a witness listen to the order is not a standard practice and may not guarantee accuracy. Choice C is incorrect as verifying the order within 12 hours may lead to delays in patient care. Choice D is incorrect because waiting for the provider to verify the order during the next in-person visit could result in a significant delay in administering necessary medication.

4. A client is scheduled for a 12-lead ECG. Which of the following actions should the nurse include in the plan of care?

• A. Ensure the client is fasting before the test
• B. Provide a warm blanket for the client
• C. Apply cold compresses to the client's chest
• D. Instruct the client to remain still

Correct answer: D

Rationale: During a 12-lead ECG, the client needs to remain still to obtain accurate readings. Therefore, instructing the client to remain still is essential. Choices A, B, and C are incorrect because fasting is not necessary for an ECG, providing a warm blanket is not a standard procedure, and applying cold compresses may interfere with the ECG results.

5. A nurse is caring for a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

• A. A fasting blood glucose of 90 mg/dL
• B. A blood glucose level of 200 mg/dL
• C. A hemoglobin A1c of 6%
• D. A fasting blood glucose of 100 mg/dL

Correct answer: B

Rationale: The correct answer is B. A blood glucose level of 200 mg/dL indicates hyperglycemia, which may necessitate insulin adjustment to better control the client's blood sugar levels. A fasting blood glucose of 90 mg/dL (choice A) is within the normal range, a hemoglobin A1c of 6% (choice C) is indicative of good long-term blood sugar control, and a fasting blood glucose of 100 mg/dL (choice D) is also within the normal range. Therefore, these findings do not require immediate reporting to the provider.

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