Nursing Elites

1. A client with a history of calcium phosphate urinary stones is being taught by a nurse. Which statements should the nurse include in this client’s dietary teaching? (Select all that apply.)

• A. Limit your intake of food high in animal protein.
• B. Read food labels to help minimize your sodium intake.
• C. A and B
• D. Reduce your intake of milk and other dairy products.

Correct answer: C

Rationale: For a client with a history of calcium phosphate urinary stones, it is essential to limit the intake of foods high in animal protein to prevent the formation of stones. Additionally, reducing sodium intake is crucial as high sodium levels can contribute to stone formation. Therefore, choices A and B are correct. Choice D, which suggests reducing intake of milk and other dairy products, is not specifically recommended for calcium phosphate stones. Clients with calcium phosphate stones should focus on limiting animal protein, sodium, and calcium intake. Choices A and B address these dietary modifications, making them the correct options for this client. Choices D, which is not directly related to calcium phosphate stones, is incorrect.

2. A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement?

• A. Position the head of the bed (HOB) flat.
• B. Withhold intravenous fluids.
• C. Administer a bolus of IV fluids.
• D. Give an antihypertensive medication.

Correct answer: D

Rationale: In a client with a completed ischemic stroke, an elevated blood pressure like 180/90 mm Hg requires immediate intervention to prevent further damage. Giving an antihypertensive medication is essential to reduce the risk of recurrent stroke or complications related to hypertension. Positioning the head of the bed flat, withholding IV fluids, or administering a bolus of IV fluids are not appropriate actions for managing elevated blood pressure in this scenario and may not address the underlying cause of the hypertension or prevent potential complications.

3. An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and complaining of a dry mouth. Which intervention should the nurse implement?

• A. Assist the client to an upright position
• B. Administer a prescribed sedative
• C. Apply a high-flow Venturi mask
• D. Encourage the client to drink water

Correct answer: A

Rationale: Assisting the client to an upright position is the most appropriate intervention in this scenario. An upright position helps optimize lung expansion and aids in improving ventilation, which can alleviate shortness of breath. This position also assists in reducing anxiety by providing a sense of control and comfort. Administering a sedative (Choice B) may further depress the respiratory drive in a client with COPD and should be avoided unless absolutely necessary. Applying a high-flow Venturi mask (Choice C) may be indicated later based on oxygenation needs, but the immediate focus should be on positioning. Encouraging the client to drink water (Choice D) may not directly address the respiratory distress and anxiety experienced by the client.

4. A nurse reviews a client’s urinalysis report. Which finding does the nurse recognize as abnormal?

• A. pH of 6.0
• B. An absence of protein
• C. The presence of ketones
• D. Specific gravity of 1.018

Correct answer: C

Rationale: The correct answer is C. The presence of ketones in the urine is abnormal. Ketones in the urine may indicate a state of ketosis, which is commonly seen in uncontrolled diabetes, fasting, or a low-carbohydrate diet. A normal pH range of urine is 4.5 to 7.8, making a pH of 6.0 within the normal range. An absence of protein is a normal finding in urine, as proteinuria (presence of protein) is abnormal. A specific gravity of 1.018 falls within the normal range of 1.016 to 1.022. Therefore, the presence of ketones is the abnormal finding in this scenario.

5. A client recovering from extracorporeal shock wave lithotripsy for renal calculi has an ecchymotic area on the right lower back. What action should the nurse take?

• A. Administer fresh-frozen plasma.
• B. Apply an ice pack to the site.
• C. Place the client in the prone position.
• D. Obtain serum coagulation test results.

Correct answer: B

Rationale: After extracorporeal shock wave lithotripsy, ecchymosis can occur due to bleeding into the tissues from the shock waves. Applying an ice pack helps reduce the extent and discomfort of bruising. Administering fresh-frozen plasma and obtaining coagulation test results are not necessary as ecchymosis after this procedure is common and does not indicate a bleeding disorder that requires immediate intervention. Placing the client in the prone position will not address the bleeding or bruising in this situation.

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