Nursing Elites

1. The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?

• A. If I exercise at least two times weekly for one hour, I will lower my cholesterol.
• B. I need to avoid eating proteins, including red meat.
• C. I will limit my intake of beef to 4 ounces per week.
• D. My blood level of low density lipoproteins needs to increase.

Correct answer: C

Rationale: Limiting saturated fat from animal food sources to no more than 4 ounces per week is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week. Red meat and all proteins do not need to be eliminated to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions. The low density lipoproteins need to decrease rather than increase.

2. The healthcare provider assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the healthcare provider do next?

• A. Apply a warm compress proximal to the site.
• B. Check for kinks in the tubing and raise the IV pole.
• C. Adjust the tape that stabilizes the needle.
• D. Flush with normal saline and recount the drop rate.

Correct answer: B

Rationale: In this scenario, the appropriate next step for the healthcare provider is to check for kinks in the tubing and raise the IV pole. These issues can commonly cause a slowed IV rate. Applying a warm compress (Choice A) may not address the underlying problem of kinked tubing or incorrect IV pole height. Adjusting the tape that stabilizes the needle (Choice C) is important for securement but is not the priority in this situation. Flushing with normal saline and recounting the drop rate (Choice D) should only be done after ruling out mechanical issues like kinks in the tubing.

3. What information should the nurse offer a client who uses herbal therapies to supplement their diet and manage common ailments about the general use of herbal supplements?

• A. Most herbs are toxic or carcinogenic and should only be used when proven effective.
• B. There is no evidence that herbs are safe or effective compared to conventional supplements in maintaining health.
• C. Herbs should be obtained from manufacturers with a history of quality control for their supplements.
• D. Herbal therapies may mask the symptoms of serious diseases, requiring frequent medical evaluations during use.

Correct answer: C

Rationale: It is essential for clients using herbal therapies to obtain herbs from manufacturers with a history of quality control for their supplements. This recommendation is crucial because quality control processes help in maintaining the purity and effectiveness of the herbal supplements. Option A is incorrect as it provides a negative and inaccurate generalization about herbs. Option B is also incorrect as there is existing evidence on the safety and efficacy of certain herbal supplements. Option D is not the most relevant information to offer initially to a client seeking advice on the general use of herbal supplements.

4. The client was placed in restraints due to confusion while hospitalized. The family removes the restraints in the client's presence. After the family leaves, what should the nurse do first?

• A. Apply the restraints to ensure the client's safety.
• B. Reassess the client to determine if restraints are still necessary.
• C. Document the time the family departed and continue monitoring the client.
• D. Contact the healthcare provider for a new order.

Correct answer: B

Rationale: In this scenario, the nurse's initial action should be to reassess the client to determine if restraints are still necessary following their removal by the family. This reassessment is crucial to evaluate the client's current condition and the need for restraints before considering reapplication. By reassessing first, the nurse ensures that the client's safety is maintained while respecting their autonomy. While documentation and monitoring are important, reassessment takes priority to provide individualized and appropriate care to the client. Contacting the healthcare provider for a new order should occur after reassessment if restraints are deemed necessary.

5. The healthcare provider receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the healthcare provider implement first?

• A. Check the drainage tubing for a kink
• B. Review the intake and output record
• C. Notify the healthcare provider
• D. Give the client 8 oz of water to drink

Correct answer: A

Rationale: The first intervention should be to check the drainage tubing for a kink. This step is crucial as any kinks in the tubing could obstruct urine flow, leading to a decreased output. By ensuring the tubing is free from any obstructions, the healthcare provider can address a potential mechanical issue causing the low output before considering other interventions. Reviewing the intake and output record may provide valuable information but should come after ensuring the tubing is clear. Notifying the healthcare provider can be done later if needed, but the immediate concern is to check for any obstructions. Giving the client water to drink may be necessary depending on the assessment findings, but addressing a possible kink in the tubing takes precedence.

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