Nursing Elites

1. The nurse cares for a client receiving furosemide (Lasix). The nurse determines that teaching is effective if the client selects which of the following foods?

• A. One medium baked potato
• B. One slice of white bread
• C. One medium apple
• D. One scrambled egg

Correct answer: A

Rationale: The correct answer is A: One medium baked potato. Potatoes are high in potassium, which is essential for clients on Lasix to prevent hypokalemia. Furosemide is a loop diuretic that can cause potassium depletion, so consuming potassium-rich foods like baked potatoes can help maintain normal potassium levels. Choices B, C, and D do not provide a significant source of potassium, which is crucial for clients on furosemide therapy.

2. The nurse is caring for a client diagnosed with rule-out nephritic syndrome. Which intervention should be included in the plan of care?

• A. Monitor the urine for bright-red bleeding
• B. Evaluate the calorie count of the 500-mg protein diet
• C. Assess the client’s sacrum for dependent edema
• D. Monitor for a high serum albumin level

Correct answer: C

Rationale: Assessing the client’s sacrum for dependent edema is crucial in the care plan for nephritic syndrome as it is common due to protein loss. Dependent edema occurs as a result of decreased oncotic pressure from protein loss in the urine. Monitoring urine for bright-red bleeding (choice A) is more relevant to conditions like glomerulonephritis. Evaluating calorie count or protein intake (choice B) is important for other conditions but not specifically for nephritic syndrome. Monitoring for a high serum albumin level (choice D) is not typically part of the immediate care plan for nephritic syndrome.

3. Determining nursing care priorities is a part of which of the following steps in determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: B

Rationale: Corrected Rationale: Planning in nursing involves setting priorities based on the patient's needs, resources, and desired outcomes. It includes organizing and coordinating care activities to achieve the identified goals. Therefore, determining nursing care priorities is a key aspect of the planning phase.\n Incorrect Rationales:\n- Evaluation (Choice A) comes after implementing the care plan to assess the effectiveness of interventions and make necessary adjustments.\n- Implementation (Choice C) is the phase where the care plan is put into action, involving carrying out the nursing interventions designed during the planning phase.\n- Assessment (Choice D) is the initial step in the nursing process where data about the patient's health status is collected and analyzed to identify needs and formulate a care plan. It precedes planning and determining care priorities.

4. A client diagnosed with acute pancreatitis has developed a pseudocyst that ruptures. Which procedure should the nurse anticipate the healthcare provider ordering?

• A. Paracentesis
• B. Chest tube insertion
• C. Lumbar puncture
• D. Biopsy of the pancreas

Correct answer: B

Rationale: The correct answer is B: Chest tube insertion. A chest tube may be needed if a pancreatic pseudocyst ruptures into the pleural space, causing a pleural effusion. Paracentesis (choice A) involves the removal of fluid from the abdominal cavity, not typically indicated for a pancreatic pseudocyst. Lumbar puncture (choice C) is a procedure to collect cerebrospinal fluid from the spinal canal, not relevant to a pancreatic pseudocyst. Biopsy of the pancreas (choice D) is a diagnostic procedure to obtain tissue samples for examination and is not typically done in the context of a ruptured pseudocyst.

5. Which laboratory data indicate the client’s pancreatitis is improving?

• A. The amylase and lipase serum levels are decreased
• B. The white blood cell count (WBC) is decreased
• C. The conjugated and unconjugated bilirubin levels are decreased
• D. The blood urea nitrogen (BUN) serum level is decreased

Correct answer: A

Rationale: The correct answer is A. Amylase and lipase are enzymes specifically related to pancreatitis. A decrease in their serum levels indicates improvement in pancreatitis. White blood cell count (WBC), choices C and D, are not direct markers for pancreatitis improvement. Bilirubin levels, choice C, are more related to liver function rather than pancreatitis. Blood urea nitrogen (BUN) level, choice D, is a marker for kidney function, not pancreatitis.

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