Nursing Elites

1. A client requires seclusion to prevent harm to others on the unit. What action should the nurse take?

• A. Offer fluids every 2 hours.
• B. Document the client's behavior prior to being placed in seclusion.
• C. Discuss the client's inappropriate behavior prior to seclusion.
• D. Assess the client's behavior every hour.

Correct answer: B

Rationale: The correct answer is to document the client's behavior prior to being placed in seclusion. Documenting the behavior is crucial as it ensures that the decision to use seclusion is based on appropriate justifications and helps in monitoring the client's progress and response to the intervention. Offering fluids every 2 hours (Choice A) is not directly related to the need for seclusion. Discussing the client's behavior prior to seclusion (Choice C) may not be appropriate at the moment when immediate action is required to prevent harm. Assessing the client's behavior every hour (Choice D) is important but not as immediate as documenting the behavior prior to seclusion.

2. A client practicing Orthodox Judaism informs the nurse they are observing the Passover holiday. Which action should the nurse include in the plan of care?

• A. Provide chicken with cream sauce
• B. Avoid serving fish with fins and scales
• C. Provide unleavened bread
• D. Avoid serving foods containing lamb

Correct answer: C

Rationale: During the Passover holiday, individuals practicing Orthodox Judaism follow dietary restrictions that include consuming unleavened bread. This symbolizes the haste with which the Israelites left Egypt and the lack of time for bread to rise. Providing chicken with cream sauce (Choice A) is not aligned with Passover dietary restrictions. Avoiding serving fish with fins and scales (Choice B) is a general dietary law in Judaism but not specific to Passover. Similarly, avoiding foods containing lamb (Choice D) is not a specific requirement during Passover.

3. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. What dietary instruction should the nurse provide?

• A. Take magnesium hydroxide for indigestion.
• B. Drink at least 3L of fluid daily.
• C. Eat 1g/kg of protein per day.
• D. Consume foods high in potassium.

Correct answer: C

Rationale: For a client with chronic kidney disease receiving hemodialysis, consuming 1g/kg of protein per day is important. This amount helps manage the condition without overburdening the kidneys. Choice A is incorrect because magnesium hydroxide is not specifically recommended for clients with chronic kidney disease. Choice B is not accurate as fluid intake needs to be individualized based on the client's condition and dialysis status. Choice D is incorrect because foods high in potassium should generally be limited for individuals with kidney disease undergoing hemodialysis to prevent hyperkalemia.

4. A nurse is planning care for a client who had gastric bypass surgery 1 week ago and has signs of early dumping syndrome. Which of the following findings should the nurse expect?

• A. Facial flushing
• B. Syncope
• C. Diaphoresis
• D. Bradycardia

Correct answer: A

Rationale: Facial flushing is a common symptom of early dumping syndrome, which occurs when food moves too quickly into the small intestine. This rapid movement triggers the release of vasoactive peptides causing vasodilation, leading to facial flushing. Syncope (choice B) is not a typical finding in early dumping syndrome. Diaphoresis (choice C) and bradycardia (choice D) are also not characteristic symptoms of early dumping syndrome.

5. A nurse is providing dietary teaching to a client with chronic kidney disease. Which of the following foods should the nurse recommend?

• A. Canned soup
• B. Bananas
• C. White bread
• D. Processed meats

Correct answer: C

Rationale: The correct answer is C: White bread. White bread is low in potassium, making it a suitable choice for clients with chronic kidney disease to prevent hyperkalemia. Canned soup (choice A), bananas (choice B), and processed meats (choice D) are high in potassium and should be limited or avoided by individuals with chronic kidney disease to manage their condition effectively.

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