Nursing Elites

1. A nurse is providing dietary teaching for a client with chronic kidney disease. What should be emphasized?

• A. Increase protein intake to promote healing
• B. Limit intake of potassium and phosphorus
• C. Increase fluid intake to prevent dehydration
• D. Encourage the intake of high-sodium foods

Correct answer: B

Rationale: The correct answer is to emphasize limiting the intake of potassium and phosphorus for a client with chronic kidney disease. Excessive intake of potassium and phosphorus can lead to complications in kidney disease patients. Choice A is incorrect because increasing protein intake can put additional stress on the kidneys. Choice C is incorrect as excessive fluid intake can worsen kidney function in such clients. Choice D is incorrect as encouraging high-sodium foods can lead to fluid retention and hypertension, which are not beneficial for individuals with chronic kidney disease.

2. A client receiving chemotherapy has developed stomatitis. Which of the following interventions should the nurse implement?

• A. Provide lemon-glycerin swabs
• B. Encourage the client to eat soft foods
• C. Avoid using toothpaste
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: B

Rationale: The correct intervention for a client with stomatitis is to encourage them to eat soft foods. Soft foods help prevent further irritation of the mouth, making it easier for the client to eat and reducing discomfort. Providing lemon-glycerin swabs could be too harsh on the already irritated mucosa. Avoiding toothpaste is relevant for clients with stomatitis to prevent further irritation. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol can further irritate the mucosa.

3. A client receiving IV fluids has developed phlebitis. What action should the nurse take next after removing the IV catheter?

• A. Place a warm compress over the IV site
• B. Record the findings in the client's chart
• C. Notify the client's primary care provider
• D. Insert a new IV catheter

Correct answer: A

Rationale: After removing an IV catheter due to phlebitis, the next step is to apply a warm compress over the IV site. This helps reduce inflammation and discomfort for the client. Recording the findings in the client's chart is important for documentation purposes but not the immediate next step. Notifying the client's primary care provider may be necessary depending on the severity of the phlebitis, but it is not the initial action. Inserting a new IV catheter is not appropriate until the phlebitis has resolved.

4. A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of membranes following a vaginal examination. The provider reports the client's cervix is dilated to 1 cm with an unengaged presenting part. Which of the following actions should the nurse take?

• A. Encourage the client to bear down
• B. Apply the external fetal monitor
• C. Provide the client with fluids
• D. Administer IV fluids

Correct answer: B

Rationale: In this scenario, with the client's cervix dilated to only 1 cm and an unengaged presenting part, the priority action is to apply the external fetal monitor. This allows for continuous monitoring of the fetal heart rate during early labor, which is crucial for assessing fetal well-being. Encouraging the client to bear down is not appropriate at 1 cm dilation, as it may not be effective and can lead to exhaustion. Providing the client with fluids or administering IV fluids may be necessary for hydration, but the immediate concern is monitoring fetal well-being.

5. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

• A. Offer small amounts of clear liquids 6 hr following surgery.
• B. Give cromolyn nebulizer solution every 6 hr.
• C. Apply a warm compress to the operative site every 4 hr.
• D. Administer analgesics on a scheduled basis for the first 24 hr.

Correct answer: D

Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial to ensure adequate pain control in the immediate postoperative period. Choice A is incorrect because clear liquids are typically initiated gradually and advanced as tolerated but not specifically at 6 hours post-surgery. Choice B is incorrect as cromolyn nebulizer solution is not indicated for postoperative pain management in this scenario. Choice C is incorrect as applying a warm compress may not be appropriate for the operative site after appendicitis surgery and can potentially increase the risk of infection.

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