Nursing Elites

1. What intervention would be the most important for the nurse to implement for the client with a left nephrectomy?

• A. Assess the intravenous fluids for rate and volume
• B. Change the surgical dressing every day at the same time
• C. Monitor the client’s medication levels daily
• D. Monitor the percentage of each meal eaten

Correct answer: A

Rationale: The most important intervention for a client with a left nephrectomy is to assess the intravenous fluids for rate and volume. After nephrectomy, monitoring intravenous fluids is crucial to ensure proper hydration and kidney function. Changing the surgical dressing daily, monitoring medication levels, and tracking meal intake are also important aspects of care but not as critical as ensuring adequate intravenous fluid management post-surgery.

2. When assessing the integumentary system of a client with anorexia nervosa, which finding would support the diagnosis?

• A. Preoccupation with calories
• B. Thick body hair
• C. Sore tongue
• D. Dry, brittle hair

Correct answer: D

Rationale: The correct answer is D: Dry, brittle hair. Dry, brittle hair is a common sign of malnutrition, often seen in clients with anorexia nervosa. Preoccupation with calories (choice A) is more related to the psychological aspect of anorexia rather than a physical finding. Thick body hair (choice B) is not typically associated with anorexia nervosa. A sore tongue (choice C) can be seen in conditions like vitamin deficiencies or oral health issues but is not specific to anorexia nervosa.

3. The nurse is caring for a client whose religious background is Seventh Day Adventist (Church of GOD). Which nursing action(s) are most appropriate in terms of providing for the dietary needs of this client? Select all that apply.

• A. Providing snacks between meals
• B. Excluding caffeine and pork from the client's diet
• C. Removing coffee from the breakfast tray
• D. Ensuring that there is no pork on the dinner tray

Correct answer: B

Rationale: The correct answer is B. Seventh Day Adventists typically avoid caffeine and pork due to religious dietary restrictions. Providing snacks between meals (choice A) is not specifically related to the dietary needs of this client. While removing coffee from the breakfast tray (choice C) aligns with the client's dietary restrictions, ensuring no pork on the dinner tray (choice D) is redundant as it is already covered in the correct answer. Therefore, choices C and D are not necessary to include as separate options.

4. The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:

• A. Provide nutrients
• B. Increase protein stores
• C. Elevate the circulating blood volume
• D. Divert blood flow away from the liver temporarily

Correct answer: C

Rationale: The correct answer is C: Elevate the circulating blood volume. Salt-poor albumin is given to increase the circulating blood volume, which helps reduce ascites by improving fluid distribution within the body. Choices A, B, and D are incorrect because salt-poor albumin is not administered to provide nutrients, increase protein stores, or divert blood flow away from the liver.

5. The nurse cares for a client receiving furosemide (Lasix). The nurse determines that teaching is effective if the client selects which of the following foods?

• A. One medium baked potato
• B. One slice of white bread
• C. One medium apple
• D. One scrambled egg

Correct answer: A

Rationale: The correct answer is A: One medium baked potato. Potatoes are high in potassium, which is essential for clients on Lasix to prevent hypokalemia. Furosemide is a loop diuretic that can cause potassium depletion, so consuming potassium-rich foods like baked potatoes can help maintain normal potassium levels. Choices B, C, and D do not provide a significant source of potassium, which is crucial for clients on furosemide therapy.

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