Nursing Elites

1. 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.

2. A client with COPD is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?

• A. Administer oxygen at 2 L/min via nasal cannula
• B. Encourage pursed-lip breathing
• C. Position the client in high Fowler's position
• D. Encourage deep breathing and coughing

Correct answer: B

Rationale: The correct intervention for a client with COPD is to encourage pursed-lip breathing. Pursed-lip breathing helps maintain airway patency by preventing the collapse of small airways during exhalation, improving breathing efficiency. Administering oxygen at 2 L/min via nasal cannula may be appropriate for some COPD patients but is not the priority intervention. Positioning the client in high Fowler's position may help improve breathing but is not as specific as pursed-lip breathing for COPD. Encouraging deep breathing and coughing may be beneficial in other respiratory conditions, but it is not the most effective intervention for COPD.

3. A client with a pressure ulcer is being cared for by a nurse. Which of the following is the most appropriate action?

• A. Use a phenol solution to clean the wound
• B. Place a warm compress over the wound
• C. Cleanse the wound from the center outwards
• D. Administer antibiotics prophylactically

Correct answer: C

Rationale: Cleaning a wound from the center outwards is the most appropriate action as it helps prevent the spread of infection. Choice A is incorrect as phenol solutions can be harmful to the wound and delay healing. Choice B may increase the risk of infection as warmth can promote bacterial growth. Choice D is unnecessary unless there are signs of infection present.

4. What is the correct way to assess for pitting edema?

• A. Press over the bony area for 5 seconds and release
• B. Press over the skin for 10 seconds and check for discoloration
• C. Press the area and check for the presence of rash
• D. Press the skin and assess for rebound tenderness

Correct answer: A

Rationale: The correct way to assess for pitting edema is to press over a bony area, typically the tibia, for 5 seconds and then release. This allows for the identification of pitting edema, characterized by an indentation that persists for a few seconds. Choice B is incorrect as pitting edema assessment does not involve checking for discoloration. Choice C is incorrect as the presence of a rash is not indicative of pitting edema. Choice D is incorrect as rebound tenderness is a different assessment used for abdominal conditions, not for pitting edema.

5. What is the most important intervention for a client with delirium?

• A. Administer sedative medication
• B. Identify any reversible causes of delirium
• C. Provide a low-stimulation environment
• D. Increase environmental stimulation

Correct answer: B

Rationale: The correct answer is to identify any reversible causes of delirium. Delirium can be caused by various factors such as infections, medications, or metabolic imbalances. Addressing these underlying causes can help resolve delirium. Administering sedative medication (Choice A) can worsen delirium by further altering mental status. Providing a low-stimulation environment (Choice C) is helpful to manage delirium symptoms, but it is not the most important intervention. Increasing environmental stimulation (Choice D) is contraindicated in delirium as it can exacerbate confusion and agitation.

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