Nursing Elites

1. A client with chronic kidney disease is being taught by a nurse about managing protein intake. Which of the following instructions should the nurse include?

• A. You should increase your intake of high-protein foods.
• B. You should limit your intake of high-protein foods.
• C. You should avoid all protein sources to prevent further kidney damage.
• D. You should increase your intake of animal protein.

Correct answer: B

Rationale: The correct answer is B: 'You should limit your intake of high-protein foods.' Clients with chronic kidney disease should restrict their intake of high-protein foods to lessen the workload on the kidneys and prevent further kidney damage. Option A is incorrect as increasing intake of high-protein foods can exacerbate the condition. Option C is incorrect as avoiding all protein sources is not advisable, as some proteins are essential for overall health. Option D is incorrect as increasing the intake of animal protein can put more strain on the kidneys due to the metabolites produced during protein breakdown.

2. What is the most important assessment for a patient with suspected pneumonia?

• A. Monitor lung sounds
• B. Check oxygen saturation
• C. Assess for cough
• D. Assess for fever

Correct answer: A

Rationale: The most important assessment for a patient with suspected pneumonia is to monitor lung sounds. Lung sounds provide crucial information about the severity of pneumonia, such as crackles or decreased air entry. This assessment helps in evaluating the effectiveness of ventilation and oxygenation. While checking oxygen saturation is important, monitoring lung sounds gives more direct information about the lung involvement in pneumonia. Assessing for cough and fever are also relevant but do not provide as direct and critical information as monitoring lung sounds in the context of suspected pneumonia.

3. A client is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Temperature of 37.1°C (98.8°F)
• C. Serosanguineous wound drainage
• D. Urine output of 25 mL/hr

Correct answer: D

Rationale: A urine output of 25 mL/hr is a sign of oliguria, which may indicate dehydration or kidney impairment and should be reported. A heart rate of 90/min is within the normal range (60-100/min) for adults at rest and may be expected postoperatively. A temperature of 37.1°C (98.8°F) is within the normal range (36.1-37.2°C or 97-99°F) and does not indicate an immediate concern. Serosanguineous wound drainage is a common finding postoperatively and indicates a normal healing process.

4. A nurse is planning care for a client who is receiving hemodialysis. What action should the nurse include in the plan?

• A. Withhold all medications until after dialysis.
• B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
• C. Check the vascular access site for bleeding after dialysis.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: C

Rationale: The correct action that the nurse should include in the plan for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is important to prevent complications such as infection or excessive bleeding. Withholding all medications until after dialysis (Choice A) is not necessary unless specific medications need to be avoided due to the dialysis process. Rehydrating with dextrose 5% in water for orthostatic hypotension (Choice B) is not directly related to post-dialysis care. Giving an antibiotic 30 minutes before dialysis (Choice D) is not a standard practice unless there is a specific clinical indication.

5. A healthcare professional is preparing to administer enoxaparin to a client. Which of the following actions should the healthcare professional take?

• A. Administer the medication intramuscularly.
• B. Inject the medication into the lateral abdominal wall.
• C. Massage the injection site after administration.
• D. Discard the prefilled syringe after expelling the air bubble.

Correct answer: B

Rationale: The correct answer is to inject the medication into the lateral abdominal wall when administering enoxaparin. This is the recommended technique to ensure proper absorption and prevent tissue damage. Choice A is incorrect because enoxaparin should be administered subcutaneously, not intramuscularly. Choice C is incorrect as massaging the injection site after administration is not recommended, as it can cause bruising and discomfort. Choice D is incorrect because the prefilled syringe should not be discarded after expelling the air bubble; it should be used for the injection.

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