Nursing Elites

1. A client is being assessed for dehydration. Which of the following findings should the nurse expect?

• A. Elevated blood pressure
• B. Increased skin turgor
• C. Dark-colored urine
• D. Bradypnea

Correct answer: C

Rationale: Dark-colored urine is a common sign of dehydration as the urine becomes concentrated. Dehydration leads to reduced fluid intake or excessive fluid loss, causing the urine to be darker in color due to increased urine concentration. Elevated blood pressure (Choice A) is not typically associated with dehydration; instead, dehydration often leads to low blood pressure. Increased skin turgor (Choice B) is actually a sign of good hydration, not dehydration. Bradypnea (Choice D), which refers to abnormally slow breathing, is not a common finding in dehydration.

2. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

3. A client has a new diagnosis of lactose intolerance and is receiving teaching from a nurse about dietary management. Which of the following statements should the nurse include in the teaching?

• A. You should avoid foods that contain lactose.
• B. You should increase your intake of high-fiber foods.
• C. You should avoid foods that contain gluten.
• D. You should increase your intake of dairy products.

Correct answer: A

Rationale: The correct statement for the nurse to include in teaching a client with lactose intolerance is to avoid foods that contain lactose. Lactose intolerance results from the body's inability to digest lactose, a sugar found in dairy products. By avoiding foods containing lactose, the client can manage symptoms and prevent complications associated with lactose intolerance. Choices B, C, and D are incorrect. Increasing intake of high-fiber foods (choice B) may be beneficial for general health but is not directly related to lactose intolerance. Avoiding gluten (choice C) is necessary for individuals with celiac disease, not lactose intolerance. Increasing intake of dairy products (choice D) would worsen symptoms in individuals with lactose intolerance due to the lactose content.

4. A client has a new diagnosis of hyperkalemia and is receiving teaching from a healthcare provider on dietary management. Which of the following statements should the healthcare provider include in the teaching?

• A. You should increase your intake of potassium-rich foods.
• B. You should decrease your intake of potassium-rich foods.
• C. You should avoid foods that contain lactose.
• D. You should increase your intake of dairy products.

Correct answer: B

Rationale: The correct answer is B: 'You should decrease your intake of potassium-rich foods.' Hyperkalemia is a condition characterized by excess potassium in the blood. To manage hyperkalemia effectively, it is crucial to reduce the intake of potassium-rich foods. This helps in lowering the overall potassium levels in the body and prevents complications associated with hyperkalemia. Choices A, C, and D are incorrect. Increasing the intake of potassium-rich foods (Choice A) would exacerbate hyperkalemia. Avoiding foods that contain lactose (Choice C) is not directly related to managing hyperkalemia. Increasing the intake of dairy products (Choice D) is not recommended as they can be a significant source of dietary potassium.

5. A client has a new diagnosis of hyperlipidemia and is receiving teaching from a nurse about dietary management. Which of the following statements should the nurse include in the teaching?

• A. You should increase your intake of trans fats.
• B. You should decrease your intake of fiber-rich foods.
• C. You should avoid foods that are high in cholesterol.
• D. You should increase your intake of high-fat foods.

Correct answer: C

Rationale: The correct statement the nurse should include in teaching the client with hyperlipidemia is to avoid foods that are high in cholesterol. Foods high in cholesterol, like those high in saturated and trans fats, can contribute to elevated lipid levels and increase cardiovascular risk. Decreasing intake of these foods can help improve lipid profiles and reduce the risk of complications. Choices A, B, and D are incorrect because increasing intake of trans fats, decreasing fiber-rich foods, and increasing intake of high-fat foods can exacerbate hyperlipidemia and worsen the lipid profile.

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