Nursing Elites

1. A client is experiencing an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take?

• A. Encourage the client to increase dietary fiber.
• B. Maintain the client on a low-residue diet.
• C. Provide the client with frequent high-calorie snacks.
• D. Encourage the client to eat a high-fiber diet.

Correct answer: B

Rationale: During an acute exacerbation of Crohn's disease, the nurse should maintain the client on a low-residue diet. This diet helps to minimize bowel irritation by reducing the volume and frequency of stools. Choices A, C, and D are incorrect. Encouraging the client to increase dietary fiber (Choice A) and eat a high-fiber diet (Choice D) can worsen symptoms and aggravate bowel inflammation in Crohn's disease. Providing the client with frequent high-calorie snacks (Choice C) may not be appropriate during an exacerbation since high-fat foods can be harder to digest and may exacerbate symptoms.

2. A healthcare professional is assessing a client who is receiving opioid analgesics. Which of the following findings should the professional report to the provider?

• A. Oxygen saturation of 94%
• B. Blood pressure of 110/70 mm Hg
• C. Respiratory rate of 12/min
• D. Heart rate of 88/min

Correct answer: C

Rationale: A respiratory rate of 12/min may indicate respiratory depression, a potential side effect of opioid analgesics. Respiratory depression can be a serious complication that requires immediate intervention. Monitoring the respiratory rate is crucial in clients receiving opioids to prevent adverse events. Oxygen saturation, blood pressure, and heart rate are important parameters to assess, but a low respiratory rate is a more critical finding that warrants immediate reporting to the healthcare provider.

3. A client who has a new prescription for lisinopril is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I should avoid using salt substitutes while taking this medication.
• B. I should take this medication with food to prevent nausea.
• C. I should increase my intake of potassium-rich foods while taking this medication.
• D. I should limit my fluid intake while taking this medication.

Correct answer: A

Rationale: The correct answer is A. Lisinopril can increase potassium levels, so clients should avoid salt substitutes that contain potassium. Choice B is incorrect because lisinopril is usually taken on an empty stomach. Choice C is incorrect because lisinopril can lead to hyperkalemia, so increasing potassium-rich foods is not recommended. Choice D is incorrect because lisinopril can cause increased urination, so fluid intake should not be limited.

4. A client receiving chemotherapy is being taught about infection prevention by a nurse. Which of the following instructions should the nurse include?

• A. Wear a mask when gardening.
• B. Avoid crowds to reduce the risk of infection.
• C. You should take a daily vitamin to prevent infection.
• D. Increase your intake of high-protein foods.

Correct answer: B

Rationale: The correct answer is B: 'Avoid crowds to reduce the risk of infection.' Clients receiving chemotherapy are immunocompromised, so avoiding crowds can help decrease the likelihood of exposure to infections. Wearing a mask when gardening (choice A) is important but not directly related to infection prevention in the context of chemotherapy. Taking a daily vitamin (choice C) may be beneficial for overall health but is not specifically focused on infection prevention. Increasing intake of high-protein foods (choice D) is essential for nutrition but does not directly address infection prevention.

5. A nurse is developing a care plan for a client who is receiving nitroprusside for severe hypertension. Which action should the nurse include?

• A. Administer calcium gluconate at the bedside.
• B. Monitor blood pressure every 2 hours.
• C. Limit light exposure to the infusion.
• D. Keep the client on NPO status.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client receiving nitroprusside for severe hypertension is to limit light exposure to the infusion. Nitroprusside is light-sensitive, so it should be protected from light exposure to prevent degradation. Administering calcium gluconate at the bedside is not directly related to nitroprusside administration. Monitoring blood pressure every 2 hours is a good practice but is not specifically related to the administration of nitroprusside. Keeping the client on NPO status is not necessary solely based on receiving nitroprusside.

Similar Questions