Nursing Elites

1. A client who practices Orthodox Judaism informs the nurse that he cannot eat certain foods during the Passover holiday. Which of the following actions should the nurse include in the plan of care?

• A. Serve 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 adhere to specific dietary restrictions, which include consuming unleavened bread. Providing unleavened bread aligns with the client's religious beliefs and dietary requirements. Choices A, B, and D are incorrect. Serving chicken with cream sauce, avoiding fish with fins and scales, and avoiding foods containing lamb are not directly related to the dietary restrictions observed during the Passover holiday in Orthodox Judaism.

2. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client's contractions are occurring every 45 seconds with a nine-second duration, and the fetal heart rate is 170 to 180 beats per minute. Which of the following actions should the nurse take?

• A. Discontinue oxytocin infusion
• B. Increase oxytocin infusion
• C. Decrease oxytocin infusion
• D. Maintain oxytocin infusion

Correct answer: A

Rationale: In this scenario, the client is experiencing frequent contractions with a short duration and an elevated fetal heart rate, indicating potential fetal distress. Discontinuing the oxytocin infusion is crucial to prevent further complications and restore normal fetal parameters. Increasing or maintaining the oxytocin infusion could exacerbate the situation, leading to more distress for the fetus. Decreasing the oxytocin infusion may not be sufficient to address the current issue and could delay the improvement of fetal well-being.

3. How should a healthcare provider respond to a patient refusing a blood transfusion for religious reasons?

• A. Respect the patient's beliefs
• B. Educate the patient on the importance of the transfusion
• C. Notify the healthcare provider
• D. Persuade the patient to accept the transfusion

Correct answer: A

Rationale: When a patient refuses a blood transfusion for religious reasons, the healthcare provider should respect the patient's beliefs. It is crucial to uphold the patient's autonomy and right to make decisions about their care, even if the provider disagrees. Educating the patient on the importance of the transfusion may be appropriate in some cases, but the initial response should always be to respect the patient's decision. Notifying the healthcare provider is not necessary as the decision lies with the patient. Persuading the patient to accept the transfusion goes against the principle of respecting the patient's autonomy and beliefs.

4. A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

• A. Glucose 180 mg/dL
• B. Sodium 136 mEq/L
• C. Potassium 3.8 mEq/L
• D. Albumin 3.5 g/dL

Correct answer: A

Rationale: The correct answer is A: "Glucose 180 mg/dL." Elevated glucose levels in a client receiving TPN may indicate hyperglycemia, which can lead to complications such as osmotic diuresis, dehydration, and electrolyte imbalances. It is essential to report this finding to the provider for further evaluation and management. Choices B, C, and D are within normal ranges and do not indicate immediate concerns related to TPN administration.

5. What lab value should a healthcare provider monitor for a patient on warfarin therapy?

• A. Potassium
• B. PT/INR
• C. Sodium
• D. Calcium

Correct answer: B

Rationale: The correct answer is B: PT/INR. When a patient is on warfarin therapy, healthcare providers monitor the PT/INR levels to evaluate the effectiveness of the treatment and assess the risk of bleeding. Monitoring potassium, sodium, or calcium levels is not directly related to warfarin therapy and would not provide the necessary information needed to manage the medication effectively.

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