Nursing Elites

1. A nurse is caring for a client with encephalopathy secondary to liver failure. The client has been prescribed a high-calorie, low-protein diet. Which of the following meal selections is appropriate for this client?

• A. Scrambled eggs, bacon, and pancakes
• B. Grilled cheese sandwich, potato chips, chocolate pudding
• C. Steak, French fries, corn
• D. Chicken breast, mashed potatoes, spinach

Correct answer: D

Rationale: The correct answer is D: Chicken breast provides a low-fat protein source, and mashed potatoes and spinach provide high-calorie nutrients suitable for managing liver failure. Option A (Scrambled eggs, bacon, and pancakes) is high in protein, which is not suitable for a low-protein diet. Option B (Grilled cheese sandwich, potato chips, chocolate pudding) contains high protein and may not be appropriate for the client. Option C (Steak, French fries, corn) is high in protein and fat, which are not recommended for this client's dietary requirements.

2. A nurse is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the nurse identify as examples of cultural variables?

• A. Eye contact
• B. Personal space
• C. Touch
• D. All of the above

Correct answer: D

Rationale: In a cultural assessment, it is essential to consider various cultural variables that can impact communication and interactions. Eye contact, personal space, and touch are examples of cultural variables that can vary among different cultural groups. These variables influence how individuals perceive and engage in communication. Understanding and respecting these differences are crucial for effective and culturally sensitive care. Therefore, the correct answer is 'All of the above.' Choices A, B, and C are incorrect because each of them represents a cultural variable that should be considered during a cultural assessment.

3. A nurse is assessing a client who has a femur fracture and is in skeletal traction. Which of the following findings should the nurse report to the provider?

• A. Clear fluid drainage from the pin sites
• B. Client reporting intermittent muscle spasms
• C. Client reporting severe pain despite receiving analgesics
• D. The traction weights are hanging freely

Correct answer: C

Rationale: The correct answer is C. Severe pain that is not relieved by analgesics may indicate neurovascular compromise or other complications and requires immediate attention by the provider. Choices A, B, and D are incorrect because clear fluid drainage from the pin sites is expected in skeletal traction, intermittent muscle spasms are common in this situation, and traction weights hanging freely indicate proper traction alignment.

4. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which type of immunity?

• A. Innate immunity
• B. Passive immunity
• C. Acquired immunity
• D. Natural immunity

Correct answer: C

Rationale: The correct answer is C: Acquired immunity. Acquired immunity occurs when an individual is given a vaccine or immunization to develop antibodies. This type of immunity is specific and develops after exposure to an antigen. Innate immunity (choice A) is the body's natural defense system present at birth. Passive immunity (choice B) is temporary immunity passed from one individual to another. Natural immunity (choice D) refers to immunity that is not gained through medical intervention or deliberate exposure.

5. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate via IV infusion. Which of the following findings indicates magnesium toxicity?

• A. Blood glucose of 150 mg/dL
• B. Urine output of 20 mL/hour
• C. Systolic blood pressure of 140 mm Hg
• D. BUN 20 mg/dL

Correct answer: B

Rationale: The correct answer is B. A urine output of 20 mL/hour is a sign of magnesium toxicity because decreased urine output can lead to accumulation of magnesium. Choices A, C, and D are not indicators of magnesium toxicity. Elevated blood glucose, high systolic blood pressure, and normal BUN levels do not specifically point towards magnesium toxicity.

Similar Questions