Nursing Elites

1. A nurse is planning care for a client who has ascites secondary to liver disease. Which of the following interventions should the nurse include in the plan of care?

• A. Reduce complex carbohydrates to 30% of total calories.
• B. Restrict protein intake to less than 0.8 g/kg/day.
• C. Decrease daily caloric intake by 20%.
• D. Limit sodium to 2000 mg or less per day.

Correct answer: D

Rationale: Limiting sodium to 2000 mg or less per day helps manage fluid retention associated with ascites in liver disease.

2. A home health nurse is conducting an initial visit with an older adult client. The client lives alone and has difficulty preparing his own meals. Which of the following actions should the nurse take first?

• A. Discuss nutritional requirements with the client.
• B. Refer the client to a senior citizen center.
• C. Arrange for a home-delivered meal program.
• D. Perform a nutrition screening.

Correct answer: D

Rationale: Performing a nutrition screening first allows the nurse to assess the client's nutritional status and identify specific needs.

3. A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

• A. Measure the client’s gastric residual every 12 hr.
• B. Obtain the client’s electrolyte levels every 4 hr.
• C. Keep the client’s head elevated at 15* during feedings.
• D. Flush the client’s tube with 30 mL of water every 4 hr.

Correct answer: D

Rationale: Flushing the client's tube with 30 mL of water every 4 hours helps maintain tube patency and prevent blockages.

4. A nurse is caring for a client who reports she is having difficulty losing weight. Which of the following responses by the nurse is appropriate?

• A. Eat small portions of the high-calorie foods first.
• B. Set a goal and you will be able to attain it.
• C. It is helpful to self-monitor your eating.
• D. Taste food while cooking to help curb your appetite.

Correct answer: C

Rationale: Self-monitoring dietary intake is an evidence-based strategy that enhances awareness and accountability, making it an effective approach for weight management.

5. A nurse is preparing to remove a client’s clogged NG tube prior to re-inserting a new tube. Which of the following actions should the nurse take first?

• A. Assist the client to blow her nose.
• B. Ask the client to take a deep breath and hold it.
• C. Pinch the proximal end of the tube.
• D. Disconnect the tube from suction source.

Correct answer: D

Rationale: Disconnecting the tube from the suction source is the first step in safely removing a clogged NG tube.

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