Nursing Elites

1. Which meal option should the nurse recommend for a client with renal disease who is following a low-protein diet?

• A. Grilled chicken with steamed vegetables
• B. Tofu stir-fry with rice
• C. Pasta with marinara sauce
• D. Baked salmon with quinoa

Correct answer: C

Rationale: The correct answer is C: Pasta with marinara sauce. Clients with renal disease following a low-protein diet should opt for lower-protein options. Pasta with marinara sauce is a suitable choice as it is lower in protein compared to grilled chicken, tofu, or salmon. Grilled chicken, tofu, and salmon are higher in protein content and are not ideal for individuals following a low-protein diet for renal disease as they may strain the kidneys.

2. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

• A. Disconnect the client from the ventilator and use a manual resuscitation bag
• B. Perform a quick assessment of the client's condition
• C. Call the respiratory therapist for help
• D. Press the alarm reset button on the ventilator

Correct answer: B

Rationale: The correct answer is to perform a quick assessment of the client's condition when the high-pressure alarm goes off on the ventilator. This assessment is crucial to determine the cause of the alarm and the client's current status. Option A is incorrect because disconnecting the client from the ventilator without assessing the situation can be harmful. Option C is incorrect as the nurse should first assess the client before seeking additional help. Option D is incorrect because resetting the alarm without understanding the underlying issue may lead to potential risks to the client.

3. A client with hyperthyroidism is admitted for total thyroidectomy. What is the nurse's priority post-operative intervention?

• A. Monitor the client's calcium levels for hypocalcemia.
• B. Monitor for signs of respiratory distress.
• C. Administer oral calcium supplements.
• D. Elevate the head of the bed to 45 degrees.

Correct answer: A

Rationale: The correct answer is to monitor the client's calcium levels for hypocalcemia. After a total thyroidectomy, there is a risk of accidental removal or damage to the parathyroid glands, leading to hypocalcemia. This complication can manifest within the first 24-48 hours post-op. Monitoring calcium levels is crucial to prevent serious complications such as tetany or seizures. While monitoring for respiratory distress is important, it is not the priority in this case. Administering oral calcium supplements should only be done based on the healthcare provider's prescription and after assessing the client's calcium levels. Elevating the head of the bed to 45 degrees is beneficial for respiratory function but is not the priority intervention for a client at risk for hypocalcemia post-thyroidectomy.

4. A client with heart failure is receiving furosemide. What assessment finding indicates the medication is effective?

• A. Increased urine output and weight loss.
• B. Increased heart rate and blood pressure.
• C. Decreased edema and improved peripheral pulses.
• D. Decreased shortness of breath and clear lung sounds.

Correct answer: C

Rationale: The correct answer is C: 'Decreased edema and improved peripheral pulses.' In a client with heart failure, furosemide is a diuretic that helps reduce fluid overload. Therefore, a decrease in edema (swelling due to fluid retention) and improved peripheral pulses (indicating better circulation) are signs that the medication is effective. Choices A, B, and D are incorrect. Increased urine output and weight loss (Choice A) may indicate the diuretic effect of furosemide but do not specifically reflect its effectiveness in heart failure. Increased heart rate and blood pressure (Choice B) are not desired effects of furosemide and may suggest adverse reactions. Decreased shortness of breath and clear lung sounds (Choice D) are related to improved respiratory status and may not directly reflect the effectiveness of furosemide in addressing fluid overload.

5. What is the first action the nurse should take when treating a 6-year-old child who stepped on a rusty nail?

• A. Cleanse the foot with soap and water
• B. Instruct the parent about tetanus boosters
• C. Apply a sterile dressing and refer for a tetanus booster
• D. Elevate the foot and wrap in a compression bandage

Correct answer: B

Rationale: The correct first action when a 6-year-old child steps on a rusty nail is to instruct the parent about tetanus boosters. This is important because stepping on a rusty nail increases the risk of tetanus infection. Choice A is incorrect as cleansing the foot comes after addressing the tetanus risk. Choice C is not the first action and should be done after addressing the immediate risk of tetanus. Choice D is not necessary as the priority is to prevent tetanus infection.

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