Nursing Elites

1. A client has a new diagnosis of hypertension and is being taught about dietary management. Which of the following statements should be included by the healthcare provider?

• 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 B: 'Decrease your intake of sodium-rich foods.' When managing hypertension, reducing the intake of sodium-rich foods is essential. Excessive sodium can contribute to increased blood pressure, which is why limiting its consumption is crucial to prevent complications. Choices A, C, and D are incorrect. Increasing sodium intake would exacerbate hypertension, avoiding lactose is unrelated to managing hypertension, and increasing dairy product intake does not specifically address the issue of sodium intake in hypertension management.

2. A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30°
• B. Flush the tube with 50 mL of water every 2 hours
• C. Replace the feeding bag and tubing every 72 hours
• D. Check the client's gastric residual every 8 hours

Correct answer: A

Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.

3. While assessing a client with fluid volume deficit, which of the following findings should the nurse expect?

• A. Bradycardia
• B. Increased skin turgor
• C. Dry mucous membranes
• D. Hypertension

Correct answer: C

Rationale: Dry mucous membranes are a classic clinical manifestation of fluid volume deficit. Dehydration leads to reduced fluid intake or excessive fluid loss, resulting in decreased moisture in the mucous membranes. Bradycardia, increased skin turgor, and hypertension are not typically associated with fluid volume deficit. Bradycardia is more commonly seen in conditions like hypothyroidism or increased intracranial pressure. Increased skin turgor is a sign of dehydration, not deficit. Hypertension is not a typical finding in fluid volume deficit.

4. A nurse is providing discharge teaching to a client who has a prescription for digoxin. Which of the following instructions should the nurse include?

• A. Take your pulse before taking the medication.
• B. Take the medication with an antacid.
• C. Double the dose if you miss one.
• D. Take the medication with a high-fiber meal.

Correct answer: A

Rationale: The correct answer is A: 'Take your pulse before taking the medication.' When administering digoxin, it is crucial to monitor the pulse rate because digoxin can cause bradycardia (slow heart rate). Checking the pulse helps in assessing the heart rate before taking the medication, as bradycardia is a common side effect of digoxin. Choice B is incorrect because digoxin should not be taken with antacids, as they can reduce its absorption. Choice C is incorrect; the dose should never be doubled if a dose is missed. Choice D is incorrect because taking digoxin with a high-fiber meal can also affect its absorption. Therefore, the essential instruction for the client is to monitor the pulse before taking digoxin.

5. What action should a healthcare provider take for a client with a new colostomy?

• A. Empty the colostomy bag when it is half full.
• B. Place aspirin in the colostomy bag to decrease odor.
• C. Use sterile technique when caring for the stoma.
• D. Change the pouch every 8 hours.

Correct answer: A

Rationale: Emptying the colostomy bag when it is half full is crucial to prevent leakage and detachment from the skin. This practice helps to maintain the integrity of the colostomy system, reducing the risk of skin irritation and odor. It is essential for client comfort and overall stoma care.

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