Nursing Elites

1. A client with chronic kidney disease is prescribed a low-potassium diet. Which food should the nurse instruct the client to avoid?

• A. Carrots
• B. White bread
• C. Bananas
• D. Apples

Correct answer: C

Rationale: The correct answer is C: Bananas. Bananas are high in potassium and should be avoided in clients who are on a low-potassium diet due to chronic kidney disease. Foods like apples and white bread are low in potassium and are safer choices. Carrots are also low in potassium and do not need to be avoided in this case.

2. A client with chronic heart failure is admitted with worsening dyspnea. What is the nurse's priority action?

• A. Administer oxygen at 2 liters per nasal cannula.
• B. Administer a diuretic as prescribed.
• C. Assess the client's lung sounds.
• D. Reposition the client to relieve dyspnea.

Correct answer: A

Rationale: In a client with chronic heart failure experiencing worsening dyspnea, the priority action for the nurse is to administer oxygen at 2 liters per nasal cannula. This helps improve oxygenation and alleviate respiratory distress. Administering a diuretic (Choice B) may be necessary but addressing oxygenation comes first. While assessing lung sounds (Choice C) is important, it is not the immediate priority when the client is in respiratory distress. Repositioning the client (Choice D) may help with comfort but does not address the underlying issue of inadequate oxygenation.

3. A client with hypocalcemia is receiving calcium gluconate. What assessment finding requires immediate intervention?

• A. Decreased deep tendon reflexes.
• B. Wheezing and stridor.
• C. Decreased bowel sounds.
• D. Positive Chvostek's sign.

Correct answer: B

Rationale: Wheezing and stridor may indicate a severe allergic reaction to calcium gluconate, such as anaphylaxis, which requires immediate intervention. While hypocalcemia can present with decreased deep tendon reflexes and positive Chvostek's sign, these findings do not indicate an immediate life-threatening situation. Decreased bowel sounds are not directly related to a severe reaction to calcium gluconate and do not require immediate intervention.

4. The nurse is preparing to administer an intramuscular injection to an adult client. Which site should the nurse select?

• A. Deltoid muscle
• B. Ventrogluteal muscle
• C. Vastus lateralis muscle
• D. Dorsogluteal muscle

Correct answer: B

Rationale: The ventrogluteal site is preferred for intramuscular injections in adults because it is free from major blood vessels and nerves, reducing the risk of injury. The deltoid muscle can be used for smaller volumes of medication, primarily vaccines. The vastus lateralis muscle is commonly used in infants, toddlers, and young children. The dorsogluteal muscle site is discouraged due to its proximity to the sciatic nerve, increasing the risk of injury or nerve damage.

5. The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process?

• A. Assist a client post cerebral vascular accident to ambulate
• B. Feed a 2-year-old in balanced skeletal traction
• C. Care for a client with discharge orders
• D. Collect a sputum specimen for acid-fast bacillus

Correct answer: C

Rationale: Caring for a client with discharge orders involves tasks that require critical thinking and clinical judgment, which are beyond the scope of a UAP. Delegating this task to a UAP can compromise patient safety and outcomes. The correct answer is C. Choices A, B, and D are appropriate tasks to delegate to a UAP based on their training and scope of practice. Assisting a client to ambulate, feeding a pediatric patient in traction, and collecting a sputum specimen are tasks that can be safely performed by a UAP under appropriate supervision.

Similar Questions