Nursing Elites

1. A client with glomerulonephritis is placed on a low-sodium diet. Which of the following snacks is suitable for the client with sodium restriction?

• A. Peanut butter cookies
• B. Grilled cheese sandwich
• C. Cottage cheese and fruit
• D. Fresh peach

Correct answer: D

Rationale: The correct answer is a fresh peach. It is the most suitable snack for a client with sodium restriction as it is naturally low in sodium. Peanut butter cookies (choice A), grilled cheese sandwich (choice B), and cottage cheese and fruit (choice C) contain higher amounts of sodium, making them unsuitable choices for someone on a low-sodium diet. Fresh fruits like peaches are excellent options for individuals on a low-sodium diet as they are not only low in sodium but also provide essential nutrients and hydration.

2. Which of the following statements by a client with spinal cord injury indicates a need for further teaching by the nurse regarding bowel management?

• A. "I should avoid eating foods that produce gas."?
• B. "I should drink more fluids like water and non-caffeinated fruit juices."?
• C. "I should set a regular schedule for bowel movements."?
• D. "I should sit in an upright position for bowel movements."?

Correct answer: B

Rationale: The corrected statement indicates the need for further teaching because it suggests consuming fluids like fruit juices, which can include caffeinated options that may stimulate fluid loss through increased urination. It is more appropriate to emphasize the consumption of fluids like water and non-caffeinated fruit juices for proper hydration. Choices A, C, and D demonstrate a correct understanding of bowel management by focusing on dietary considerations, establishing a regular bowel movement schedule, and using proper positioning during bowel movements. Option B is incorrect as it may lead to increased fluid loss due to caffeine content in some fruit juices.

3. Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:

• A. A cephalohematoma
• B. Molding
• C. Subdural hematoma
• D. Caput succedaneum

Correct answer: A

Rationale: The correct answer is A, a cephalohematoma. A cephalohematoma is an area of bleeding outside the cranium but beneath the periosteum, typically not crossing the suture line. Answer B, molding, is the overlapping of the bones of the cranium and does not involve bleeding, making it an incorrect choice. Answer C, a subdural hematoma, involves intracranial bleeding and is typically diagnosed through imaging studies like a CAT scan or x-ray. Answer D, caput succedaneum, is characterized by edema that crosses the suture line, unlike the described swelling in this case.

4. The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain which type of culture?

• A. Blood
• B. Nasopharyngeal secretions
• C. Stool
• D. Genital secretions

Correct answer: D

Rationale: A culture for gonorrhea is taken from the genital secretions as gonorrhea primarily affects the genital area. The culture is incubated in a warm environment to promote the growth of Neisseria gonorrhoeae, the bacterium causing gonorrhea. Genital secretions provide a direct sample from the site of infection, increasing the accuracy of diagnosis. Choices A, B, and C are incorrect as they are not suitable specimens for diagnosing gonorrhea. Blood cultures are used to detect bloodstream infections, nasopharyngeal secretions are collected for respiratory infections, and stool cultures are done to identify gastrointestinal infections, none of which are related to gonorrhea.

5. During the history assessment of an 80-year-old client, which statement made by the client might indicate a possible fluid and electrolyte imbalance?

• A. "My skin is always so dry."?
• B. "I often use a laxative for constipation."?
• C. "I have always liked to drink a lot of iced tea."?
• D. "I sometimes have a problem with dribbling urine."?

Correct answer: B

Rationale: The correct answer is "I often use a laxative for constipation." Frequent use of laxatives can lead to diarrhea and electrolyte loss, indicating a possible fluid and electrolyte imbalance. Statements A, C, and D are not directly related to fluid and electrolyte imbalance. Statement A about dry skin may suggest dehydration, but it is less specific to electrolyte imbalance than the frequent use of laxatives. Statement C about drinking a lot of iced tea could potentially relate to fluid intake, but it doesn't directly indicate an imbalance. Statement D about dribbling urine is more indicative of a potential urinary issue rather than a fluid and electrolyte imbalance.

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