Nursing Elites

1. A nurse is collecting data from a client who has diabetes and is overweight. The client tells the nurse that she wants to start an exercise program. Which of the following actions should the nurse take first?

• A. Determine the client's usual pattern of activity.
• B. Assist the client in developing a healthy eating plan.
• C. Encourage the client to join a support group.
• D. Provide the client with a list of signs and symptoms to report to the provider.

Correct answer: A

Rationale: Assessing the client's usual pattern of activity is crucial as it helps the nurse understand the client's current level of physical activity, any limitations, and areas needing improvement. This information is essential to create a safe and effective exercise plan tailored to the client's specific needs. Choice B, assisting the client in developing a healthy eating plan, is important but not the first step when the client's immediate goal is to start an exercise program. Encouraging the client to join a support group may be beneficial for motivation and emotional support but is not the priority at this stage. Providing a list of signs and symptoms to report to the provider is important for client education but is not the initial step when the client expresses a desire to begin an exercise program.

2. A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse recommend the family members to omit?

• A. Boiled rice
• B. Italian bread
• C. Broiled salmon filet
• D. Pickled beets

Correct answer: D

Rationale: The correct answer is D, Pickled beets. Pickled foods often contain high levels of sodium, which should be avoided in a low-sodium diet. Boiled rice, Italian bread, and broiled salmon filet are generally lower in sodium compared to pickled beets, making them more suitable choices for a client on a low-sodium diet.

3. A 14-year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statement by the client would be most indicative of the etiology of this crisis?

• A. I knew this would happen. I've been eating too much red meat lately.
• B. I really enjoyed my fishing trip yesterday. I caught 2 fish.
• C. I have really been working hard practicing with the debate team at school.
• D. I went to the healthcare provider last week for a cold, and I have gotten worse.

Correct answer: D

Rationale: The correct answer is D because a recent illness, such as a cold, can trigger a vaso-occlusive crisis in sickle cell disease. This crisis is often precipitated by infections or other illnesses that cause a systemic inflammatory response, leading to vaso-occlusion. Choices A, B, and C do not directly relate to the etiology of a vaso-occlusive crisis in sickle cell disease, making them incorrect.

4. What is the most effective nursing intervention to prevent atelectasis from developing in a postoperative client?

• A. Maintain adequate hydration
• B. Assist the client to turn, deep breathe, and cough
• C. Ambulate the client within 12 hours
• D. Splint the incision

Correct answer: B

Rationale: The correct answer is to assist the client to turn, deep breathe, and cough. This intervention helps to expand the lungs and prevent atelectasis in postoperative clients. Maintaining adequate hydration is important for overall health but is not the most effective intervention for preventing atelectasis. Ambulating the client within 12 hours is beneficial for preventing complications after surgery, but it may not be as directly effective in preventing atelectasis as turning, deep breathing, and coughing. Splinting the incision is important for postoperative care, but it does not specifically address the prevention of atelectasis.

5. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?

• A. Clamp the chest tube
• B. Call the surgeon immediately
• C. Prepare for blood transfusion
• D. Continue to monitor the rate of drainage

Correct answer: D

Rationale: In this scenario, the most appropriate nursing action is to continue to monitor the rate of drainage. Clamping the chest tube is not recommended as it can lead to a tension pneumothorax. Calling the surgeon immediately may not be necessary at this point unless the drainage rate significantly increases or other concerning symptoms develop. Preparing for a blood transfusion is premature without further assessment and monitoring of the client's condition. Monitoring the rate of drainage allows the nurse to assess for any potential complications and ensure that the drainage amount is within expected limits.

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