Nursing Elites

1. The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow?

• A. Increase intake of high-fiber foods, such as bran cereal
• B. Restrict protein intake by limiting meats and other high-protein foods.
• C. Limit oral fluid intake to 500ml per day
• D. Increase intake of potassium-rich foods such as bananas and cantaloupe.

Correct answer: B

Rationale: The correct answer is B: Restrict protein intake by limiting meats and other high-protein foods. In glomerulonephritis, reducing protein intake helps to lower the workload on the kidneys, as excessive protein can lead to increased production of waste products that the kidneys must filter. This restriction can help prevent further damage to the kidneys. Choices A, C, and D are incorrect because: A) Increasing high-fiber foods like bran cereal is beneficial for other conditions but not specific to glomerulonephritis. C) Limiting oral fluid intake to 500ml per day is not appropriate as fluid restrictions are usually individualized based on the client's condition and kidney function. D) Increasing potassium-rich foods like bananas and cantaloupe may not be suitable for all clients with glomerulonephritis, as potassium levels can be affected in kidney disease and individual needs may vary.

2. The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. What is the most likely cause of the pain?

• A. Inflammation of the vessels
• B. Obstructed blood flow
• C. Overhydration
• D. Stress-related headaches

Correct answer: B

Rationale: The correct answer is B: Obstructed blood flow. In sickle cell anemia, the sickle-shaped red blood cells can clump together, obstructing blood flow in the vessels. This obstruction leads to tissue hypoxia (lack of oxygen) and necrosis, causing pain. Choice A, inflammation of the vessels, is not the primary cause of pain in sickle cell anemia. Choice C, overhydration, is unrelated to the pathophysiology of sickle cell anemia. Choice D, stress-related headaches, is not a characteristic symptom of sickle cell anemia.

3. The nurse is teaching a client with gastroesophageal reflux disease (GERD) about dietary modifications. Which food should the client avoid?

• A. Applesauce
• B. White rice
• C. Coffee
• D. Bananas

Correct answer: C

Rationale: The correct answer is C: Coffee. Coffee should be avoided by clients with GERD as it can relax the lower esophageal sphincter, leading to an increase in GERD symptoms. Choices A, B, and D are not directly associated with worsening GERD symptoms and can be included in moderation in the diet of a client with GERD.

4. A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply)

• A. Verify pedal pulses using a doppler pulse device.
• B. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure.
• C. Evaluate the application of the splint to the left leg.
• D.

Correct answer: C

Rationale: It is crucial for the nurse to evaluate the application of the splint to the left leg in a client with diminished distal pulses. This assessment helps ensure that the splint is not causing any compromise to circulation. Verifying pulses and monitoring for leg conditions are important interventions but do not directly address the issue with the splint application in this scenario, making them less relevant.

5. When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

• A. Obtain arterial blood gases (ABGs) before the procedure.
• B. Explain that the client may be positioned in five different ways.
• C. Assist the patient into a position that will allow gravity to move secretions.
• D. Encourage the client to practice deep breathing throughout the procedure.

Correct answer: C

Rationale: The correct approach when performing postural drainage on a client with COPD is to assist the patient into a position that allows gravity to help move secretions. This position helps drain secretions from specific segments of the lungs. Obtaining arterial blood gases (Choice A) is not directly related to postural drainage. While the client may be placed in multiple positions during postural drainage, the key is to position them to facilitate the movement of secretions, not just any five positions as mentioned in Choice B. Encouraging deep breathing (Choice D) is a good nursing intervention for overall respiratory health but is not specifically related to the technique of postural drainage.

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