Nursing Elites

1. The nurse is providing discharge teaching to a client with newly diagnosed type 2 diabetes mellitus. Which instruction is most important to prevent complications?

• A. Monitor blood glucose levels regularly
• B. Maintain a low-fat diet
• C. Exercise regularly
• D. Take medication as prescribed

Correct answer: A

Rationale: Regular monitoring of blood glucose levels is crucial in managing diabetes and preventing complications. This allows the client and healthcare team to make timely adjustments to the treatment plan. While maintaining a low-fat diet, exercising regularly, and taking medication as prescribed are all important aspects of diabetes management, monitoring blood glucose levels takes precedence as it provides real-time information about the client's condition and helps prevent acute complications.

2. A client with a history of chronic heart failure is admitted with symptoms of dyspnea and fatigue. What initial intervention should the nurse prepare to implement?

• A. Administration of IV diuretics
• B. Oxygen therapy
• C. Bed rest
• D. Dietary consultation

Correct answer: B

Rationale: The correct initial intervention for a client with chronic heart failure presenting with dyspnea and fatigue is oxygen therapy. Oxygen therapy can help relieve dyspnea and improve oxygen saturation levels, which are crucial in managing heart failure exacerbations. Administering IV diuretics may be necessary later to address fluid overload, but oxygen therapy takes precedence in addressing the immediate respiratory distress. Bed rest and dietary consultation are important aspects of care for heart failure patients, but in this scenario, oxygen therapy is the priority to improve the client's respiratory status.

3. Which client is at the highest risk for developing pressure ulcers?

• A. A 50-year-old client with a fractured femur
• B. A 30-year-old client with diabetes mellitus
• C. A 65-year-old client with limited mobility
• D. A 70-year-old client with a history of stroke

Correct answer: C

Rationale: Clients with limited mobility are at the highest risk for developing pressure ulcers due to prolonged pressure on specific areas of the body. This constant pressure can lead to tissue damage and ultimately result in pressure ulcers. While age and medical conditions such as diabetes and a history of stroke can contribute to the risk of pressure ulcers, limited mobility is the most significant factor as it directly affects the ability to shift positions and relieve pressure on vulnerable areas of the body. Therefore, the 65-year-old client with limited mobility is at the highest risk compared to the other clients. The 50-year-old client with a fractured femur may have limited mobility due to the injury, but it is temporary and may not be as prolonged as chronic limited mobility. The 30-year-old client with diabetes mellitus and the 70-year-old client with a history of stroke are at risk for developing pressure ulcers, but their conditions do not directly impact their ability to shift positions and alleviate pressure like limited mobility does.

4. A client with a severe peanut allergy accidentally ingested peanut-containing food and is experiencing anaphylaxis. What is the nurse's priority action?

• A. Administer an epinephrine injection
• B. Call for immediate medical help
• C. Monitor airway, breathing, and circulation
• D. All of the above

Correct answer: A

Rationale: The priority action for a client experiencing anaphylaxis due to a severe peanut allergy is to administer an epinephrine injection. Epinephrine is the first-line treatment for anaphylaxis as it can rapidly reverse the severe allergic reaction. While calling for immediate medical help is important, administering epinephrine takes precedence because it can be life-saving in this situation. Monitoring airway, breathing, and circulation is essential in managing anaphylaxis, but administering epinephrine is the priority action to halt the progression of the allergic reaction and stabilize the client's condition. Therefore, 'Administer an epinephrine injection' is the most critical initial intervention.

5. The client is being taught about a low-sodium diet. Which food should the client avoid?

• A. Fresh fruits
• B. Canned vegetables
• C. Fresh chicken
• D. Unsalted nuts

Correct answer: B

Rationale: The correct answer is B: Canned vegetables. Canned vegetables are often high in sodium due to the preservation process, so they should be avoided on a low-sodium diet. Fresh fruits (choice A), fresh chicken (choice C), and unsalted nuts (choice D) are all low-sodium options and can be included in a low-sodium diet. It is important to choose fresh or frozen vegetables over canned ones to reduce sodium intake. Fresh chicken and unsalted nuts are also good protein sources that are naturally low in sodium, making them suitable for a low-sodium diet. Therefore, clients following a low-sodium diet should prioritize fresh, whole foods over processed or canned options.

Similar Questions