Nursing Elites

1. A nurse is teaching a client about dietary modifications for a low-sodium diet. Which of the following should the nurse include?

• A. Limit intake of processed foods
• B. Increase intake of fresh fruits and vegetables
• C. Use of accessory muscles
• D. Monitor for allergic reactions

Correct answer: A

Rationale: The correct answer is to limit intake of processed foods. Processed foods are often high in sodium, which goes against the goal of a low-sodium diet. Fresh fruits and vegetables are recommended for a low-sodium diet due to their natural low sodium content. The use of accessory muscles and monitoring for allergic reactions are not related to dietary modifications for a low-sodium diet.

2. A nurse is planning care to prevent complications in a client with immobility. Which of the following interventions should the nurse include?

• A. Massage lower extremities daily to prevent DVT
• B. Remove anti-embolism stockings for 3 hours each day
• C. Limit intake of foods high in calcium to prevent renal calculi
• D. Encourage the client to lie supine to prevent constipation

Correct answer: B

Rationale: The correct answer is B because removing anti-embolism stockings for short periods prevents skin breakdown while ensuring that the stockings remain effective in promoting circulation. Choice A is incorrect because massaging lower extremities daily does not prevent DVT; instead, it may dislodge a clot. Choice C is incorrect as limiting intake of foods high in calcium does not prevent renal calculi; rather, it may help reduce the risk of kidney stones. Choice D is incorrect because encouraging the client to lie supine does not prevent constipation; instead, encouraging mobility and adequate fluid intake can help prevent constipation in immobile clients.

3. A hospice nurse is providing teaching to a patient who has a new diagnosis of a terminal illness and her family. Which statement should the nurse include in the teaching?

• A. Hospice care will help provide rehabilitation for the patient.
• B. Hospice care focuses on extending life by any means necessary.
• C. Hospice care will help the patient transition to nursing care.
• D. Hospice care continues to help families with grief after a death occurs.

Correct answer: D

Rationale: The correct statement that the nurse should include in the teaching is option D: 'Hospice care continues to help families with grief after a death occurs.' Hospice care not only focuses on providing comfort care for terminal patients but also offers bereavement support to families after the patient's death. Choices A, B, and C are incorrect. Option A is incorrect because hospice care does not provide rehabilitation for the patient; its focus is on comfort and quality of life. Option B is incorrect because hospice care does not aim to extend life but rather to provide quality end-of-life care. Option C is incorrect because hospice care does not transition patients to nursing care; it provides care focused on comfort and symptom management in the patient's preferred setting.

4. While reviewing the medical record of a client with unstable angina, which of the following findings should the nurse report to the provider?

• A. BP 106/62 mm Hg, Temp 38°C (100.4°F), HR 112/min, Resp rate 26/min, urine output 90 mL/hr
• B. Skin is cool and moist with pallor
• C. Bilateral breath sounds with crackles heard at bases of lungs
• D. Creatinine kinase 100 units/L, C-reactive protein 0.8 mg/dL, Myoglobin 88 mcg/L

Correct answer: A

Rationale: The correct answer is A. The nurse should report these vital signs to the provider immediately as they indicate increased temperature, tachycardia, and tachypnea, which are signs of possible infection or systemic inflammatory response. This could exacerbate the client's unstable angina and needs prompt evaluation. Choices B, C, and D are not as urgent as the vital signs in option A and do not directly indicate a worsening condition in the context of unstable angina.

5. A nurse is assessing a client who is 12 hours post-surgery. The client has an indwelling urinary catheter, and the nurse notes a urinary output of 15 mL/hr. Which of the following interventions should the nurse implement first?

• A. Irrigate the catheter
• B. Assess the patency of the catheter
• C. Increase the IV fluid rate
• D. Notify the provider

Correct answer: B

Rationale: The nurse should first assess the patency of the catheter to ensure that the low output is not caused by a blockage. It is crucial to rule out any obstructions before considering other interventions. Irrigating the catheter without verifying patency may worsen the situation if there is a blockage. Increasing IV fluid rate may not address the underlying issue if the problem lies with the catheter. Notifying the provider should come after ensuring the catheter's patency.

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