Nursing Elites

1. Which nursing intervention is best for a client with constipation?

• A. Encourage the client to remain in bed to avoid straining
• B. Administer a stool softener as prescribed
• C. Increase fiber intake through dietary changes
• D. Encourage regular exercise to promote bowel movement

Correct answer: C

Rationale: Increasing fiber intake is the most appropriate nursing intervention for a client experiencing constipation. Fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Encouraging the client to remain in bed may exacerbate constipation by reducing movement and promoting inactivity. While stool softeners can be beneficial, they are typically used as a short-term solution and may not address the underlying issue of low fiber intake. Regular exercise is important for overall bowel health; however, in the immediate management of constipation, increasing fiber intake is the most effective intervention.

2. A client has a new diagnosis of Raynaud's disease. Which of the following instructions should the nurse include?

• A. Increase your intake of foods high in potassium.
• B. Keep your home environment warm.
• C. Elevate your legs when sitting.
• D. Reduce your intake of sodium.

Correct answer: B

Rationale: The correct answer is to keep the home environment warm. Raynaud's disease causes vasospasm in response to cold, so maintaining a warm environment can help prevent attacks. Choices A, C, and D are incorrect. Increasing potassium intake, elevating legs when sitting, or reducing sodium intake are not specific to managing Raynaud's disease.

3. How should a healthcare professional assess a patient with fluid overload?

• A. Monitor weight and assess for edema
• B. Monitor blood pressure and auscultate lung sounds
• C. Assess for jugular venous distention
• D. Monitor oxygen saturation and check for fluid retention

Correct answer: A

Rationale: The correct way to assess a patient with fluid overload is by monitoring weight and assessing for edema. Weight monitoring helps in detecting fluid retention, and edema is a visible sign of excess fluid accumulation. Although monitoring blood pressure and auscultating lung sounds are important assessments in heart failure, they are not specific to fluid overload. Assessing for jugular venous distention is more indicative of right-sided heart failure rather than fluid overload. Monitoring oxygen saturation and checking for fluid retention are not primary assessments for fluid overload.

4. A nurse is caring for a client who has heart failure and is receiving digoxin. Which of the following findings should the nurse identify as a sign of digoxin toxicity?

• A. Bradycardia
• B. Tachycardia
• C. Hypotension
• D. Increased appetite

Correct answer: A

Rationale: Corrected Rationale: Bradycardia is a common sign of digoxin toxicity. Digoxin, a medication used to treat heart failure, works by slowing down the heart rate and increasing the force of heart contractions. Excessive levels of digoxin can lead to toxicity, causing bradycardia (slow heart rate), among other symptoms. Tachycardia (fast heart rate) and hypotension (low blood pressure) are not typically associated with digoxin toxicity. Increased appetite is not a recognized sign of digoxin toxicity; instead, gastrointestinal symptoms like nausea, vomiting, and anorexia are more common.

5. What is the initial step a nurse should take when irrigating a wound?

• A. Wear sterile gloves while removing the old dressing
• B. Cleanse the wound from the center outward
• C. Apply a warm compress to the wound
• D. Use a 20 mL syringe to irrigate the wound

Correct answer: B

Rationale: The correct first action when irrigating a wound is to cleanse the wound from the center outward. This method helps remove debris and pathogens effectively, reducing the risk of infection. Choice A is incorrect because wearing sterile gloves should be done before starting the wound irrigation but is not the first action in the process. Choice C is incorrect as applying a warm compress is not the initial step in wound irrigation. Choice D is also incorrect as using a syringe to irrigate the wound comes after cleansing the wound.

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