Nursing Elites

1. A client sustained a major burn over 20% of the body. What intervention should the nurse implement to meet the client's nutritional needs?

• A. Keep track of calorie intake for food and beverages.
• B. Provide a low-protein, high-carbohydrate diet.
• C. Schedule meals at 6-hour intervals.
• D. Provide a high-protein, high-calorie diet.

Correct answer: D

Rationale: The correct answer is to provide a high-protein, high-calorie diet for a client with major burns. This type of diet is essential to support healing and recovery. High-protein intake is crucial as it helps in tissue repair and wound healing, while high-calorie intake is necessary to meet the increased metabolic demands of the body during the healing process. Keeping track of calorie intake (Choice A) is important but doesn't address the specific needs of a burn patient. Providing a low-protein, high-carbohydrate diet (Choice B) is not suitable for burn patients as they require adequate protein for wound healing. Scheduling meals at 6-hour intervals (Choice C) may be helpful for maintaining a consistent eating schedule, but it is not as crucial as providing the correct high-protein, high-calorie diet.

2. A healthcare professional is assessing a client who has chronic kidney disease. Which of the following findings should the healthcare professional report to the provider?

• A. Urine output of 80 mL/hr
• B. Blood pressure of 140/90 mm Hg
• C. Serum creatinine 2.8 mg/dL
• D. Heart rate of 72/min

Correct answer: C

Rationale: The correct answer is C. A serum creatinine level of 2.8 mg/dL indicates impaired kidney function and should be reported to the healthcare provider. Elevated serum creatinine levels are indicative of decreased kidney function and potential progression of chronic kidney disease. Choices A, B, and D are within normal ranges and do not signify immediate concerns related to kidney disease. Urine output of 80 mL/hr is appropriate, a blood pressure of 140/90 mm Hg is considered prehypertensive but not acutely concerning, and a heart rate of 72/min falls within the normal range.

3. A client is receiving discharge teaching for a new prescription of digoxin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will stop taking this medication if my heart rate is below 80/min.
• B. I should take my pulse before taking this medication.
• C. I should stop taking this medication if my pulse is above 100/min.
• D. I will take this medication with an antacid.

Correct answer: B

Rationale: The correct answer is B. Clients taking digoxin should check their pulse before each dose to ensure it is within the appropriate range. Option A is incorrect because stopping the medication based solely on a heart rate below 80/min is not recommended. Option C is incorrect as having a pulse above 100/min doesn't necessarily indicate a need to stop digoxin. Option D is incorrect because digoxin should not be taken with an antacid as it can interfere with its absorption.

4. A client who is 14 weeks of gestation reports swelling of the face. What should the nurse do next?

• A. Administer an analgesic.
• B. Report this finding to the provider immediately.
• C. Administer an antiemetic.
• D. Monitor the client's vital signs.

Correct answer: B

Rationale: The correct answer is to report this finding to the provider immediately. Swelling of the face in pregnancy can be a sign of preeclampsia, a serious condition characterized by high blood pressure and signs of damage to another organ system, often the kidneys. Prompt reporting and intervention are crucial to prevent complications for both the client and the fetus. Administering an analgesic (choice A) is not appropriate for this situation as it does not address the underlying cause of the swelling. Administering an antiemetic (choice C) is used to treat nausea and vomiting, which are not the primary concerns associated with facial swelling in this scenario. Monitoring the client's vital signs (choice D) is important but should be done after reporting the finding to the provider to guide further assessment and management.

5. A client with heart failure is prescribed furosemide. What finding should the nurse report to the provider?

• A. Sodium 140 mEq/L
• B. Heart rate of 82/min
• C. Potassium level of 2.8 mEq/L
• D. Oxygen saturation 95%

Correct answer: C

Rationale: The correct answer is C. A potassium level of 2.8 mEq/L is low and should be reported to the provider. Furosemide can cause potassium depletion, leading to hypokalemia. Low potassium levels can result in cardiac dysrhythmias, which is a serious concern in clients with heart failure. Choices A, B, and D are within normal ranges and do not require immediate reporting. Sodium level of 140 mEq/L, heart rate of 82/min, and oxygen saturation of 95% are all acceptable findings.

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