Nursing Elites

1. 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.

2. A nurse is assessing a client who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect?

• A. Constipation
• B. Absent deep-tendon reflexes
• C. Nausea and vomiting
• D. Tingling of the extremities

Correct answer: D

Rationale: Correct! A calcium level of 8.0 mg/dL indicates hypocalcemia. Hypocalcemia can lead to increased neuromuscular excitability, manifesting as tingling of the extremities. Choices A, B, and C are incorrect findings associated with other electrolyte imbalances or conditions and are not typically related to hypocalcemia. Constipation is commonly seen in hypokalemia, absent deep-tendon reflexes are associated with hypermagnesemia, and nausea and vomiting are more indicative of hypercalcemia.

3. When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention?

• A. The institution's restraints/seclusion policies
• B. The patient's competence
• C. The patient's voluntary/involuntary status
• D. The patient's nursing care plan

Correct answer: C

Rationale: The correct answer is C because the patient's voluntary or involuntary status should not impact the nurse's actions when using restraints. The use of restraints should be based on the patient's behavior and the need to ensure their safety and the safety of others. Choices A, B, and D are important factors that should influence the nurse's actions. The institution's restraints/seclusion policies provide guidelines on the appropriate use of restraints, the patient's competence helps determine their understanding and ability to control their behavior, and the patient's nursing care plan guides the overall care provided, including the use of restraints if necessary.

4. What is the correct intervention for a patient experiencing anaphylaxis?

• A. Administer epinephrine
• B. Provide oxygen
• C. Monitor airway
• D. All of the above

Correct answer: D

Rationale: In cases of anaphylaxis, all of the listed interventions are crucial for effective management. Administering epinephrine is the primary treatment to reverse the allergic reaction rapidly. Providing oxygen ensures adequate oxygenation to vital organs, and monitoring the airway is essential to prevent obstruction and maintain a clear air passage. Therefore, all three interventions are necessary in managing anaphylaxis. Choices A, B, and C are not individually sufficient to address all aspects of anaphylaxis, making the comprehensive approach of 'All of the above' the correct answer.

5. A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be

• A. Confused with cold, clammy skin and a pulse of 110
• B. Lethargic with hot, dry skin and rapid, deep respirations
• C. Alert and cooperative with a BP of 130/80 and respirations of 12
• D. Short of breath, with distended neck veins and a bounding pulse of 96

Correct answer: A

Rationale: The correct answer is A. Low blood sugar levels (50 mg/dL) typically cause confusion, cold clammy skin, and an increased pulse (tachycardia). Option A correctly describes the expected symptoms of hypoglycemia, which include confusion due to the brain's inadequate glucose supply, cold and clammy skin due to sympathetic nervous system activation, and an increased pulse (110 bpm) as the body reacts to low blood sugar levels. Options B, C, and D describe symptoms that are not typically associated with hypoglycemia. Lethargy, hot dry skin, rapid deep respirations, normal vital signs, shortness of breath, distended neck veins, and bounding pulse are more indicative of other conditions or normal physiological responses, not hypoglycemia.

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