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 has pneumonia. Which of the following findings should the nurse identify as an indication of the effectiveness of the treatment?

• A. Respiratory rate of 24/min
• B. White blood cell count of 15,000/mm3
• C. SpO2 of 95%
• D. Clear breath sounds

Correct answer: D

Rationale: Clear breath sounds are an essential indicator of effective pneumonia treatment as they suggest resolution of the lung infection. A normal respiratory rate (A) indicates adequate breathing but does not directly reflect the effectiveness of pneumonia treatment. An elevated white blood cell count (B) is a sign of infection and may not decrease immediately with treatment. While maintaining an SpO2 of 95% (C) is crucial for oxygenation, it may not directly indicate the effectiveness of pneumonia treatment.

3. A nurse is caring for a client who has a new diagnosis of hypercholesterolemia. Which of the following dietary recommendations should the nurse make?

• A. Increase intake of red meat
• B. Consume foods high in saturated fats
• C. Choose foods low in trans fats
• D. Limit intake of vegetables and fruits

Correct answer: C

Rationale: The correct answer is C: 'Choose foods low in trans fats.' Trans fats are known to increase cholesterol levels, so avoiding foods high in trans fats is essential in managing hypercholesterolemia. Option A, increasing intake of red meat, and option B, consuming foods high in saturated fats, can worsen cholesterol levels as they are sources of unhealthy fats. Option D, limiting intake of vegetables and fruits, is incorrect as they are part of a heart-healthy diet and should be encouraged for individuals with hypercholesterolemia.

4. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which 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 with the client their 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 seclusion. Documenting the behavior is crucial as it helps justify the need for seclusion, provides a clear record of events leading up to the intervention, and ensures transparency in the client's care. Offering fluids every 2 hours (Choice A) is important for hydration but is not directly related to the situation of seclusion. Discussing the inappropriate behavior with the client (Choice C) may not be safe or appropriate when seclusion is necessary for preventing harm. Assessing the client's behavior every hour (Choice D) is important but may not be the most immediate action needed when seclusion is already in place.

5. What is the best method to assess for fluid overload in patients with heart failure?

• A. Monitor daily weight
• B. Check for jugular vein distention
• C. Check for pitting edema
• D. Check for fluid retention

Correct answer: A

Rationale: The correct answer is A: Monitor daily weight. Daily weight monitoring is the most accurate method to assess fluid overload in patients with heart failure. Changes in weight can indicate fluid retention before visible signs like jugular vein distention or pitting edema appear. Checking for jugular vein distention (choice B) is helpful but may not be as sensitive as daily weight monitoring. Pitting edema (choice C) and fluid retention (choice D) are signs of fluid overload, but daily weight monitoring is a more proactive approach to detect changes early.

Similar Questions