Nursing Elites

1. The nurse is teaching the client diagnosed with Type 2 diabetes mellitus about diet. Which diet selection indicates the client understands the teaching?

• A. A submarine sandwich, potato chips, and diet cola
• B. Four (4) slices of a supreme thin-crust pizza and milk
• C. Smoked turkey sandwich, celery sticks, and unsweetened tea
• D. A roast beef sandwich, fried onion rings, and a cola

Correct answer: C

Rationale: The correct answer is C because a smoked turkey sandwich with celery sticks and unsweetened tea is a healthier option for someone with Type 2 diabetes mellitus. Turkey is a lean protein source, celery sticks are low in calories and carbs, and unsweetened tea is a better choice than sugary beverages. Choices A, B, and D are incorrect. Choice A includes high-carb and high-sugar items like potato chips and diet cola, which are not ideal for diabetes management. Choice B contains a high-carb pizza and milk, which may not be suitable for controlling blood sugar levels. Choice D includes fried onion rings and cola, which are high in unhealthy fats and sugars, making it a poor choice for a diabetic diet.

2. A client scheduled for surgery cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which best action regarding the informed consent?

• A. Obtain a court order for the surgery
• B. Sign the informed consent on behalf of the client
• C. Send the client to surgery without the consent form being signed
• D. Obtain a telephone consent from a family member, with the consent being witnessed by two healthcare providers

Correct answer: D

Rationale: In situations where a client is unable to sign the consent form, obtaining a telephone consent from a family member, with the consent being witnessed by two healthcare providers, is the best course of action. This ensures that the client's best interests are considered and that proper authorization is obtained. Option A, obtaining a court order, is not necessary in this scenario and could delay the surgery. Option B, signing the consent on behalf of the client, is not appropriate as it may raise ethical and legal concerns. Option C, sending the client to surgery without a signed consent form, is not advisable as it violates the principles of informed consent and places the client at risk.

3. The nurse is preparing a teaching care plan for the client diagnosed with nephritic syndrome. Which intervention should the nurse include?

• A. Discontinue the use of steroid therapy immediately if symptoms develop.
• B. Take diuretics as needed to treat the dependent edema in ankles.
• C. Increase the intake of dietary sodium every day to decrease fluid retention.
• D. Report any decrease in daily weight during treatment to the healthcare provider.

Correct answer: D

Rationale: The correct intervention for the nurse to include in the care plan for a client diagnosed with nephritic syndrome is to instruct the client to report any decrease in daily weight during treatment to the healthcare provider. A decrease in weight could indicate worsening of the nephritic syndrome or dehydration, making it crucial information for the healthcare provider to assess the client's condition. Option A is incorrect because discontinuing steroid therapy should be done under medical guidance rather than immediately if symptoms develop. Option B is incorrect because diuretics should not be taken without healthcare provider's guidance due to the risk of electrolyte imbalances. Option C is incorrect as increasing dietary sodium would exacerbate fluid retention, which is undesirable in nephritic syndrome.

4. Which discharge instruction should the nurse provide to the client diagnosed with varicose veins who has received sclerotherapy?

• A. Walk 15 to 20 minutes three (3) times a day.
• B. Keep the legs in the dependent position when sitting.
• C. Remove compression bandages before going to bed.
• D. Perform Berger-Allen exercises (4) times a day.

Correct answer: A

Rationale: The correct answer is to instruct the client to walk 15 to 20 minutes three times a day. Walking helps improve circulation and reduces the risk of complications following sclerotherapy. Choice B, keeping the legs in the dependent position when sitting, is incorrect as it can increase venous pressure. Choice C, removing compression bandages before going to bed, is incorrect as compression should be maintained as per healthcare provider's instructions. Choice D, performing Berger-Allen exercises four times a day, is incorrect as these exercises may not be specifically recommended post-sclerotherapy.

5. Which nursing action(s) can result in disciplinary action by state boards of nursing?

• A. Release of client health information to a client’s neighbor
• B. Delegation of a dressing change to unlicensed assistive personnel (UAP)
• C. Release of client health information to the client’s durable power of attorney
• D. A, B

Correct answer: D

Rationale: The correct answer is D. Disclosing client health information to unauthorized individuals like a client's neighbor (A) and improper delegation of tasks to unlicensed personnel (B) are serious violations of patient confidentiality and safety standards, which can lead to disciplinary action by state boards of nursing. Choice C, releasing client health information to the client's durable power of attorney, is not a violation as it involves sharing information with an authorized individual. Therefore, choices A and B are incorrect, making D the correct answer.

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