Nursing Elites

1. A client with a new diagnosis of cirrhosis is receiving dietary management education from a nurse. Which of the following statements should the nurse include in the teaching?

• A. You should increase your intake of sodium-rich foods.
• B. You should decrease your intake of sodium-rich foods.
• C. You should avoid foods that contain lactose.
• D. You should increase your intake of dairy products.

Correct answer: B

Rationale: Reducing the intake of sodium-rich foods is beneficial for managing fluid retention and symptoms of cirrhosis. Excessive sodium can lead to fluid buildup in the body, worsening edema and ascites commonly associated with cirrhosis. Therefore, advising the client to decrease their intake of sodium-rich foods is crucial in the dietary management of cirrhosis. Option A is incorrect as increasing sodium intake would exacerbate fluid retention. Option C is irrelevant to cirrhosis management unless the client has lactose intolerance. Option D is incorrect as increasing dairy product intake may not be suitable for all patients with cirrhosis, especially if they have complications like hepatic encephalopathy.

2. A client receives discharge teaching on a new prescription for lisinopril. Which of the following instructions should be included?

• A. Avoid foods high in potassium.
• B. Take the medication with food.
• C. Increase your intake of salt.
• D. Take the medication at bedtime.

Correct answer: A

Rationale: The correct instruction that should be included when a client receives discharge teaching on a new prescription for lisinopril is to 'Avoid foods high in potassium.' Lisinopril, an ACE inhibitor, can lead to hyperkalemia by reducing potassium excretion. Therefore, clients taking lisinopril should be advised to avoid foods high in potassium to prevent potential complications associated with elevated potassium levels. Choices B, C, and D are incorrect because taking lisinopril with food, increasing salt intake, or taking the medication at bedtime are not specific instructions related to lisinopril therapy and may not be beneficial or necessary for the client's condition.

3. When teaching a client with a new diagnosis of heart failure about dietary management, which of the following statements should the nurse include?

• A. Increase your intake of sodium-rich foods.
• B. Decrease your intake of sodium-rich foods.
• C. Avoid foods that contain lactose.
• D. Increase your intake of dairy products.

Correct answer: B

Rationale: The correct answer is to decrease the intake of sodium-rich foods. Sodium restriction is crucial in managing heart failure as it helps to reduce fluid retention and alleviate symptoms. Excessive sodium intake can lead to fluid buildup in the body, worsening heart failure. Therefore, advising the client to decrease sodium-rich foods is essential for their overall health and management of the condition. Choices A, C, and D are incorrect. Increasing intake of sodium-rich foods (Choice A) would worsen fluid retention and heart failure symptoms. Avoiding foods that contain lactose (Choice C) is not directly related to heart failure management through sodium restriction. Increasing intake of dairy products (Choice D) may not be suitable for all heart failure patients, especially if they need to limit saturated fats or cholesterol in their diet.

4. In an emergency department, a provider is assessing a client with an acute head injury following a motor-vehicle crash. Which of the following findings should be prioritized?

• A. A Glasgow Coma Scale score of 13
• B. Clear fluid leaking from the nose
• C. Nausea and vomiting
• D. Anisocoria

Correct answer: B

Rationale: The priority finding is the clear fluid leaking from the nose, which could indicate a cerebrospinal fluid leak and potential brain injury. This requires immediate attention to assess for possible cerebrospinal fluid leak, which is a serious complication of head trauma and needs prompt intervention to prevent further complications. While a Glasgow Coma Scale score of 13 may indicate a mild alteration in consciousness, it is not as urgent as assessing for a cerebrospinal fluid leak. Nausea and vomiting are common symptoms after head injuries but do not take precedence over assessing for a potential cerebrospinal fluid leak. Anisocoria (unequal pupils) is also important to note but is not as urgent as identifying a possible cerebrospinal fluid leak in this scenario.

5. When caring for a client with a prescription for wound irrigation, which action should the nurse take?

• A. Use a 10-mL syringe with an 18-gauge needle.
• B. Cleanse the wound from the center outward.
• C. Apply a wet-to-dry dressing.
• D. Pack the wound tightly with gauze.

Correct answer: B

Rationale: When caring for a client with a prescription for wound irrigation, the nurse should cleanse the wound from the center outward. This technique helps prevent the introduction of microorganisms into the wound, reducing the risk of contamination and promoting effective wound healing. By using a circular motion from the cleanest area to the least clean areas, debris and bacteria are moved away from the wound site, decreasing the chances of infection.

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