Nursing Elites

1. The nurse supervises care of a client in Buck’s traction. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

• A. The nurse removes the foam boot three times per day to inspect the skin
• B. The staff turn the client to the unaffected side
• C. The staff turn the client to the unaffected side and the nurse asks the client to dorsiflex the foot on the affected leg
• D. The nurse asks the client to dorsiflex the foot on the affected leg

Correct answer: C

Rationale: Correct care for a client in Buck’s traction includes turning the client to the unaffected side to prevent complications such as pressure ulcers. Additionally, asking the client to dorsiflex the foot on the affected leg helps prevent foot drop. Removing the foam boot three times per day to inspect the skin is unnecessary and could disrupt the traction, so it is not appropriate. Therefore, choices A and D are incorrect.

2. The nurse is caring for a client diagnosed with rule-out nephritic syndrome. Which intervention should be included in the plan of care?

• A. Monitor the urine for bright-red bleeding
• B. Evaluate the calorie count of the 500-mg protein diet
• C. Assess the client’s sacrum for dependent edema
• D. Monitor for a high serum albumin level

Correct answer: C

Rationale: The correct intervention to include in the plan of care for a client with rule-out nephritic syndrome is to assess the client’s sacrum for dependent edema. Dependent edema is common in nephritic syndrome due to protein loss, and monitoring for this helps manage the condition. Choices A, B, and D are incorrect. Monitoring the urine for bright-red bleeding may be more relevant for a client with a different condition, such as glomerulonephritis. Evaluating the calorie count of a 500-mg protein diet is not directly related to managing nephritic syndrome. Monitoring for a high serum albumin level does not directly address the symptom of dependent edema associated with nephritic syndrome.

3. The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position:

• A. Astride one of her hips
• B. Strapped in an infant seat
• C. Wrapped tightly in a blanket
• D. Under the arm using a football hold

Correct answer: A

Rationale: The correct way to carry an infant with cerebral palsy experiencing muscle hypertonicity and scissoring of the legs is astride one of the mother's hips. This position helps keep the infant's legs apart, reducing muscle tightness. Strapping the infant in an infant seat, wrapping tightly in a blanket, or using the football hold under the arm does not address the specific needs related to muscle hypertonicity and scissoring of the legs in cerebral palsy.

4. Which of the following statements about medications is true?

• A. Over-the-counter medications are unlikely to interact with food or nutrients
• B. Prescription medications always have significant interactions with food
• C. Prescription and nonprescription drugs and herbal remedies interact with food
• D. Herbal products are generally safe since they are natural

Correct answer: C

Rationale: The correct answer is C. This statement is true because both prescription medications and over-the-counter medications, along with herbal remedies, can interact with food. Choice A is incorrect because over-the-counter medications can also interact with food or nutrients. Choice B is incorrect as not all prescription medications have significant interactions with food. Choice D is misleading because herbal products are not always safe, as they can have side effects and interact with other medications.

5. People who use monoamine oxidase inhibitors for the treatment of depression need to avoid foods high in:

• A. Folate
• B. Tyramine
• C. Potassium
• D. Vitamin K

Correct answer: B

Rationale: The correct answer is B: Tyramine. When individuals taking monoamine oxidase inhibitors (MAOIs) consume foods high in tyramine, it can lead to a potentially dangerous increase in blood pressure known as a hypertensive crisis. Foods high in tyramine include aged cheeses, cured meats, and certain fermented foods. Choices A, C, and D are incorrect. Folate, potassium, and vitamin K are not typically contraindicated with the use of MAOIs.

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