Nursing Elites

1. A client is being assessed for dehydration. Which of the following findings should the nurse expect?

• A. Elevated blood pressure
• B. Increased skin turgor
• C. Dark-colored urine
• D. Bradypnea

Correct answer: C

Rationale: Dark-colored urine is a common sign of dehydration as the urine becomes concentrated. Dehydration leads to reduced fluid intake or excessive fluid loss, causing the urine to be darker in color due to increased urine concentration. Elevated blood pressure (Choice A) is not typically associated with dehydration; instead, dehydration often leads to low blood pressure. Increased skin turgor (Choice B) is actually a sign of good hydration, not dehydration. Bradypnea (Choice D), which refers to abnormally slow breathing, is not a common finding in dehydration.

2. When teaching a client with a new diagnosis of diabetes mellitus about foot care, which of the following instructions should the nurse include?

• A. Soak your feet in hot water every day.
• B. Apply lotion between your toes.
• C. Inspect your feet daily.
• D. Use over-the-counter products to remove corns.

Correct answer: C

Rationale: Inspecting the feet daily is crucial for clients with diabetes mellitus to detect early signs of injury or infection promptly. This practice helps prevent serious complications such as diabetic foot ulcers. Soaking feet in hot water daily can lead to skin dryness and increase the risk of injury. Applying lotion between toes can cause moisture buildup, leading to fungal infections. Using over-the-counter products to remove corns can result in skin damage and should be done under healthcare provider supervision.

3. A client with a new diagnosis of cirrhosis is receiving dietary management education from a nurse. Which of the following statements should the nurse include in the teaching?

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

Correct answer: B

Rationale: Reducing the intake of sodium-rich foods is beneficial for managing fluid retention and symptoms of cirrhosis. Excessive sodium can lead to fluid buildup in the body, worsening edema and ascites commonly associated with cirrhosis. Therefore, advising the client to decrease their intake of sodium-rich foods is crucial in the dietary management of cirrhosis. Option A is incorrect as increasing sodium intake would exacerbate fluid retention. Option C is irrelevant to cirrhosis management unless the client has lactose intolerance. Option D is incorrect as increasing dairy product intake may not be suitable for all patients with cirrhosis, especially if they have complications like hepatic encephalopathy.

4. A client has been prescribed enoxaparin. Which of the following instructions should the nurse include?

• A. You need to obtain routine blood tests to monitor the effects of this medication.
• B. You should administer the medication into your thigh.
• C. You should inject the medication once daily.
• D. You need to use a 1-inch needle to administer the medication.

Correct answer: C

Rationale: The correct instruction to include when educating a client prescribed enoxaparin is to inject the medication once daily. Enoxaparin is typically administered via subcutaneous injection once daily, usually in the abdomen, to prevent blood clots.

5. 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.

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