Nursing Elites

1. A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?

• A. Have him drink several glasses of water
• B. Crede the bladder from the bottom to the top
• C. Assist him to stand by the side of the bed to void
• D. Wait 2 hours and have him try to void again

Correct answer: C

Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action. This position can help stimulate voiding due to gravity and normal positioning. Having the client drink water (Choice A) may help, but assisting him to stand is more effective. Crede maneuver (Choice B) is not recommended as it can increase the risk of bladder trauma. Waiting for 2 hours (Choice D) without taking any action is not proactive in addressing the client's inability to void.

2. After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate?

• A. 3 oz. broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
• B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
• C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
• D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

Correct answer: D

Rationale: The most appropriate meal plan for a client following a myocardial infarction and placed on a sodium-restricted diet should include fresh ingredients with low sodium content to promote heart health. Option D, which consists of 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange, aligns best with these requirements. Option A contains canned beets, which are typically high in sodium. Option B includes canned salmon, which may have added sodium. Option C has a bologna sandwich, which is processed and high in sodium. Therefore, Option D is the most suitable choice for a client needing a low-sodium diet after a heart attack.

3. In a client with chronic kidney disease having a serum potassium level of 6.5 mEq/L, which assessment is the most critical for the nurse to perform?

• A. Neurological status
• B. Cardiac status
• C. Respiratory status
• D. Gastrointestinal status

Correct answer: B

Rationale: Corrected Rationale: Assessing cardiac status is crucial in hyperkalemia as high potassium levels can result in life-threatening arrhythmias. Monitoring the heart rhythm and ECG findings is essential to prevent cardiac complications. Neurological status, respiratory status, and gastrointestinal status are important assessments too, but in the context of hyperkalemia, cardiac status takes precedence due to the immediate risk of cardiac arrhythmias.

4. A nurse is reinforcing dietary teaching with a client who has iron deficiency anemia. The nurse should explain that which of the following food sources contains iron that is most easily absorbed by the body?

• A. Spinach
• B. Dried apricots
• C. Chicken
• D. Lentils

Correct answer: C

Rationale: The correct answer is C, 'Chicken.' Heme iron from animal sources, such as chicken, is more easily absorbed by the body compared to non-heme iron from plant sources like spinach, dried apricots, and lentils. While plant-based iron sources are beneficial, they are not as readily absorbed by the body as heme iron from animal products.

5. A nurse is reinforcing teaching about foods that enhance iron absorption when consumed with nonheme iron with a client who has iron deficiency anemia. Which of the following foods should the nurse include in the teaching?

• A. Tomato juice
• B. Tea
• C. Milk
• D. Dried beans

Correct answer: A

Rationale: The correct answer is A, Tomato juice. Tomato juice is high in vitamin C, which enhances the absorption of nonheme iron from foods. Vitamin C helps convert nonheme iron to a form that is easier for the body to absorb. Tea (choice B) contains tannins that can inhibit iron absorption. Milk (choice C) contains calcium, which can interfere with iron absorption. Dried beans (choice D) are a good source of nonheme iron but do not enhance iron absorption when consumed with nonheme iron.

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