Nursing Elites

1. A client has been on bed rest for 3 days. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

• A. The client uses a walker to move from the bed to the chair.
• B. The client has a strong cough.
• C. The client can bear weight on both legs.
• D. The client has a normal respiratory rate.

Correct answer: C

Rationale: The ability to bear weight on both legs indicates muscle strength and stability necessary for ambulation. This skill is crucial for the client to support their body weight and move independently when standing or walking. Choices A, B, and D are incorrect because using a walker, having a strong cough, or having a normal respiratory rate do not directly indicate the readiness to ambulate. The key factor in determining readiness for ambulation is the client's ability to bear weight on both legs, demonstrating the necessary strength for standing and walking.

2. A client has a new diagnosis of hyperkalemia and is receiving teaching from a healthcare provider on dietary management. Which of the following statements should the healthcare provider include in the teaching?

• A. You should increase your intake of potassium-rich foods.
• B. You should decrease your intake of potassium-rich foods.
• C. You should avoid foods that contain lactose.
• D. You should increase your intake of dairy products.

Correct answer: B

Rationale: The correct answer is B: 'You should decrease your intake of potassium-rich foods.' Hyperkalemia is a condition characterized by excess potassium in the blood. To manage hyperkalemia effectively, it is crucial to reduce the intake of potassium-rich foods. This helps in lowering the overall potassium levels in the body and prevents complications associated with hyperkalemia. Choices A, C, and D are incorrect. Increasing the intake of potassium-rich foods (Choice A) would exacerbate hyperkalemia. Avoiding foods that contain lactose (Choice C) is not directly related to managing hyperkalemia. Increasing the intake of dairy products (Choice D) is not recommended as they can be a significant source of dietary potassium.

3. A client with a new diagnosis of celiac disease is being taught about dietary management. Which of the following statements should be included by the healthcare provider?

• A. You should avoid foods that contain gluten.
• B. You should increase your intake of dairy products.
• C. You should avoid foods that contain lactose.
• D. You should increase your intake of high-fiber foods.

Correct answer: A

Rationale: The correct answer is A: 'You should avoid foods that contain gluten.' Gluten is a protein found in wheat, barley, and rye, which can trigger an immune response in individuals with celiac disease. Avoiding gluten-containing foods is crucial to managing the condition and preventing symptoms and complications associated with celiac disease. Choices B, C, and D are incorrect. Increasing dairy intake (Choice B) is not necessary for celiac disease management. Avoiding lactose (Choice C) is relevant for individuals with lactose intolerance, not celiac disease. While high-fiber foods (Choice D) are generally beneficial for health, they are not specifically indicated for celiac disease management.

4. Which of the following dietary modifications should be recommended to a client with hypertension?

• A. Increase sodium intake.
• B. Reduce potassium intake.
• C. Increase fiber intake.
• D. Reduce calcium intake.

Correct answer: C

Rationale: Increasing fiber intake is a beneficial dietary modification for clients with hypertension. Fiber helps in reducing blood pressure and improving cardiovascular health by promoting better digestion and regulating cholesterol levels. Therefore, advising a client with hypertension to increase fiber intake can be beneficial for their overall health. In contrast, increasing sodium intake can lead to higher blood pressure, reducing potassium intake is not recommended as potassium helps in regulating blood pressure, and reducing calcium intake is not typically necessary for hypertension management.

5. A client has a pressure ulcer. Which of the following findings indicates healing of the ulcer?

• A. Increase in drainage.
• B. Decrease in size.
• C. Presence of foul odor.
• D. Reddened wound edges.

Correct answer: B

Rationale: When a pressure ulcer is healing, there is a decrease in its size as the tissue repair progresses. This reduction in size is a positive indication of the healing process. An increase in drainage, presence of foul odor, or reddened wound edges are typically signs of infection or lack of improvement. Therefore, the correct answer is a decrease in size.

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