Nursing Elites

1. 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.

2. The nurse is caring for a client with a new diagnosis of diabetes mellitus. Which of these statements made by the client indicates a need for further teaching?

• A. I will monitor my blood glucose levels regularly and keep a record to show my healthcare provider.
• B. I will follow my meal plan and exercise regularly to help manage my blood sugar levels.
• C. I will stop taking my medications if my blood sugar levels are normal.
• D. I will continue to take my medications even if I feel better.

Correct answer: C

Rationale: Choice C indicates a need for further teaching because stopping medications when blood sugar levels are normal can lead to uncontrolled blood sugar levels if the individual does not understand the importance of medication adherence in managing diabetes. Choices A, B, and D are correct statements that demonstrate good understanding of managing diabetes, such as monitoring blood glucose levels, following a meal plan, exercising regularly, and adhering to medication even when feeling better.

3. The parents of a child on phenytoin (Dilantin) have received discharge instructions from the nurse. Which of the following statements suggests that the teaching was effective?

• A. We will call the healthcare provider if the child develops acne.
• B. Our child should brush and floss carefully after every meal.
• C. We will skip the next dose if vomiting or fever occurs.
• D. When our child is seizure-free for 6 months, we can stop the medication.

Correct answer: B

Rationale: The correct answer is B. Proper oral hygiene, including brushing and flossing carefully after every meal, is essential for children on phenytoin to prevent gingival hyperplasia, a common side effect. Choice A is incorrect because acne is not a common side effect of phenytoin and does not require immediate healthcare provider notification. Choice C is incorrect because vomiting or fever should not prompt skipping a dose without consulting the healthcare provider first. Choice D is incorrect because discontinuing phenytoin should never be done abruptly or without healthcare provider guidance, even if the child is seizure-free for 6 months.

4. A nurse at a provider's office is reinforcing teaching with a client who is being treated with chemotherapy and is losing weight. Which of the following instructions should the nurse give to increase the client's caloric intake? (Select one that doesn't apply).

• A. Top yogurt with granola.
• B. Use honey on toast.
• C. Use milk instead of water in recipes.
• D. Increase fluids during meals.

Correct answer: D

Rationale: Increasing fluids during meals does not directly contribute to increasing caloric intake. Topping yogurt with granola, using honey on toast, and using milk instead of water in recipes are effective ways to boost caloric intake. While adequate fluid intake is important for hydration and overall health, it does not address the specific need to increase caloric intake in this scenario.

5. A nurse is reinforcing teaching to a group of older adults about sources of complete and incomplete protein. Which of the following foods should the nurse include as a complete protein?

• A. Yogurt
• B. Fresh vegetables
• C. Nuts
• D. Dried beans

Correct answer: A

Rationale: Corrected Rationale: Yogurt contains all essential amino acids, making it a complete protein. Choice B, fresh vegetables, are incomplete proteins. Choice C, nuts, are also incomplete proteins. Choice D, dried beans, are incomplete proteins. Therefore, the correct answer is yogurt because it is a source of complete protein.

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