Nursing Elites

1. The nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?

• A. Request an occupational therapy consult to determine the need for assistive devices
• B. Assign assistive personnel to perform self-care tasks for the client
• C. Instruct the client to focus on gradually resuming self-care tasks
• D. Ask the client if a family member is available to assist with his care

Correct answer: C

Rationale: Instructing the client to focus on gradually resuming self-care tasks is the most appropriate strategy to promote independence while managing fatigue. This approach encourages the client to regain autonomy by engaging in self-care activities at their own pace. Requesting an occupational therapy consult (Choice A) may be beneficial but does not directly address the client's concern regarding fatigue and self-care. Assigning assistive personnel (Choice B) may hinder the client's independence by taking over tasks the client could potentially perform. Asking about family assistance (Choice D) does not empower the client to regain self-care abilities.

2. Which dietary advice is most appropriate for a client with chronic kidney disease?

• A. Increase intake of fruits and vegetables
• B. Limit intake of potassium-rich foods
• C. Increase intake of dairy products
• D. Reduce intake of protein-rich foods

Correct answer: B

Rationale: The most appropriate dietary advice for a client with chronic kidney disease is to limit intake of potassium-rich foods. In chronic kidney disease, the kidneys have difficulty filtering potassium from the blood, leading to high levels that can be harmful. Therefore, reducing potassium intake is crucial to prevent complications. Choices A, C, and D are not the best options for individuals with chronic kidney disease. Increasing intake of fruits and vegetables (choice A) may actually increase potassium consumption. Increasing intake of dairy products (choice C) can lead to higher phosphorus and potassium levels. Reducing protein-rich foods (choice D) is not the primary focus in the early stages of chronic kidney disease, as protein is necessary for overall health unless kidney function declines significantly.

3. A nurse is teaching a client who has gastroesophageal reflux disease (GERD) about ways to reduce symptoms. Which of the following instructions should the nurse include?

• A. Avoid lying down after meals
• B. Eat large meals to reduce acid production
• C. Drink carbonated beverages with meals
• D. Consume spicy foods to improve digestion

Correct answer: A

Rationale: The correct answer is A: 'Avoid lying down after meals.' This instruction is important for clients with GERD as it helps reduce reflux symptoms. Lying down after meals can worsen GERD symptoms by allowing stomach acid to flow back into the esophagus. Choice B is incorrect because eating large meals can actually increase acid production and exacerbate GERD symptoms. Choice C is incorrect as carbonated beverages can trigger acid reflux in individuals with GERD. Choice D is also incorrect because consuming spicy foods can irritate the esophagus and lead to increased reflux symptoms.

4. During a presentation on basic first aid, a nurse educator evaluates a newly licensed home health nurse's understanding of heat stroke. Which symptom indicates the client has heat stroke?

• A. Hypotension
• B. Bradycardia
• C. Clammy skin
• D. Bradypnea

Correct answer: A

Rationale: The correct answer is A: Hypotension. Heat stroke can lead to hypotension, which is low blood pressure. This is a common symptom of heat stroke and requires immediate intervention. Bradycardia (slow heart rate), clammy skin, and bradypnea (slow breathing) are not typically associated with heat stroke. In heat stroke, the body's temperature regulation system fails, leading to a rapid rise in body temperature, which can cause various symptoms including hypotension.

5. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?

• A. Use sterile gloves
• B. Lubricate the catheter with water
• C. Insert the catheter using clean technique
• D. Open the catheterization kit away from the body

Correct answer: D

Rationale: The correct action for the nurse to take when preparing to insert an indwelling urinary catheter is to open the catheterization kit away from the body. This is crucial to maintain the sterility of the kit and the procedure. Using sterile gloves (Choice A) is important, but it is not specific to this step. Lubricating the catheter with water (Choice B) is incorrect as it should be lubricated with a water-soluble lubricant. Inserting the catheter using clean technique (Choice C) is incorrect as indwelling urinary catheter insertion requires sterile technique to prevent infections.

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