Nursing Elites

1. A client with hypertension is prescribed a low-sodium diet. Which food should the client avoid?

• A. Fresh fruits
• B. Processed cheese
• C. Whole grain bread
• D. Fresh vegetables

Correct answer: B

Rationale: The correct answer is B: Processed cheese. Processed cheese is high in sodium and should be avoided in a low-sodium diet for clients with hypertension. Fresh fruits, whole grain bread, and fresh vegetables are generally low in sodium and can be part of a healthy diet for clients with hypertension.

2. The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply)

• A. Abdominal obesity
• B. Blood pressure of 150/96 mmHg
• C. Increased triglyceride levels
• D. All of the above

Correct answer: D

Rationale: The correct answer is D, as all the listed factors - abdominal obesity, high blood pressure, and increased triglyceride levels - are components of metabolic syndrome. Addressing these findings is crucial to help reduce the client's risk for developing diabetes mellitus and vascular disease. Abdominal obesity is a key feature of metabolic syndrome, high blood pressure (150/96 mmHg) is a risk factor, and increased triglyceride levels are also indicative of the syndrome. Educating the client on lifestyle modifications, such as healthy eating habits, regular physical activity, and monitoring these parameters, is essential in managing metabolic syndrome and preventing associated complications. Choices A, B, and C are all correct, making choice D the correct answer.

3. The nurse is providing postoperative care for a client who had a thyroidectomy. Which assessment finding requires immediate intervention?

• A. Hoarseness and weak voice
• B. Calcium level of 8.0 mg/dL (2.0 mmol/L)
• C. Heart rate of 110 beats per minute
• D. Difficulty swallowing

Correct answer: D

Rationale: Difficulty swallowing can indicate swelling or hematoma formation, which may compromise the airway and requires immediate intervention. Hoarseness and a weak voice are expected post-thyroidectomy due to manipulation of the laryngeal nerves but do not require immediate intervention. A calcium level of 8.0 mg/dL is within the normal range (8.5-10.5 mg/dL) and may not require immediate intervention. A heart rate of 110 beats per minute may be elevated due to stress or pain postoperatively, but it does not indicate an immediate threat to the airway.

4. A client with ulcerative colitis is experiencing frequent diarrhea. What is the priority nursing diagnosis?

• A. Risk for impaired skin integrity
• B. Fluid volume deficit
• C. Imbalanced nutrition: less than body requirements
• D. Activity intolerance

Correct answer: B

Rationale: The correct answer is B: Fluid volume deficit. In a client with ulcerative colitis experiencing frequent diarrhea, the priority nursing diagnosis is addressing the potential fluid volume deficit due to significant fluid loss. Maintaining adequate hydration is crucial to prevent complications associated with dehydration. While choices A, C, and D can also be concerns for a client with ulcerative colitis, addressing fluid volume deficit takes precedence as it directly impacts the client's physiological stability and can lead to serious complications if not managed promptly.

5. A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post-anesthesia unit. Before selecting which medication to administer, which action should the nurse implement?

• A. Document the client's report of pain in the electronic medical record.
• B. Determine which prescription will have the quickest onset of action.
• C. Compare the client's pain scale rating with the prescribed dosing.
• D. Ask the client to choose which medication is needed for the pain.

Correct answer: C

Rationale: The correct action the nurse should implement before selecting which medication to administer to a postoperative client who reports incisional pain is to compare the client's pain scale rating with the prescribed dosing. This ensures that the client receives the appropriate medication based on their pain level. Documenting the client's report of pain in the electronic medical record (Choice A) is important but should come after ensuring the right medication is given. Determining which prescription will have the quickest onset of action (Choice B) may not be the most relevant factor to consider when choosing the appropriate medication. Asking the client to choose the medication needed for the pain (Choice D) may not be appropriate as the nurse should rely on the pain scale rating and prescribed dosing to make a clinical decision.

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