Nursing Elites

1. During an admission interview, a nurse is assessing a client's personal identity. Which of the following questions should the nurse ask?

• A. What is your marital status?
• B. How would you describe yourself?
• C. Are you employed?
• D. Do you have any children?

Correct answer: B

Rationale: When assessing personal identity, it is important to ask questions that prompt clients to describe themselves. Question B, 'How would you describe yourself?' is the most appropriate as it allows the client to share their own perceptions and characteristics, aiding in understanding their personal identity. Choices A, C, and D are more focused on specific personal details such as marital status, employment status, and parental status, which do not directly contribute to understanding personal identity.

2. A healthcare provider is caring for a client who is receiving IV therapy via a peripheral catheter. The healthcare provider should identify that which of the following findings is an indication of infiltration?

• A. Redness at the infusion site
• B. Edema at the infusion site
• C. Warmth at the infusion site
• D. Oozing of blood at the infusion site

Correct answer: B

Rationale: Edema at the infusion site is an indication of infiltration, where fluid leaks into the surrounding tissues causing swelling. This can compromise the delivery of medication and fluids, potentially leading to complications. Redness, warmth, and oozing of blood are more suggestive of inflammation or infection rather than infiltration. Infiltration requires prompt recognition and intervention to prevent further issues with the IV therapy.

3. A healthcare professional is planning care for a client who has a new prescription for a high-protein diet. Which of the following foods should the healthcare professional recommend?

• A. Nuts
• B. Bananas
• C. Potatoes
• D. Apples

Correct answer: A

Rationale: Nuts are an excellent source of protein and are suitable for a high-protein diet. They provide essential nutrients and can help the client meet their increased protein requirements. Bananas, potatoes, and apples are not high-protein foods and are not the best choice when aiming to increase protein intake.

4. A client with a new diagnosis of hypertension is being taught about lifestyle changes. Which of the following statements should the nurse include in the teaching?

• A. You should limit your alcohol intake to no more than one drink per day.
• B. You should increase your sodium intake to at least 2,300 mg per day.
• C. You should limit your physical activity to avoid increasing your blood pressure.
• D. You should avoid eating dairy products to help lower your blood pressure.

Correct answer: A

Rationale: The correct statement to include in teaching a client with hypertension is to limit alcohol intake to no more than one drink per day. Excessive alcohol consumption can raise blood pressure and lead to complications. Increasing sodium intake, limiting physical activity, and avoiding dairy products are not recommended for managing hypertension. Clients with hypertension should follow a heart-healthy diet low in sodium, engage in regular physical activity, and monitor their blood pressure regularly to control hypertension effectively.

5. A healthcare professional is preparing to administer a cleansing enema to a client. Which of the following actions should the healthcare professional plan to take?

• A. Insert the rectal tube 15.2 cm (6 inches) into the client's rectum
• B. Wear clean gloves before inserting the tubing
• C. Position the client on their left side
• D. Hold the solution bag 91 cm (36 inches) above the client's rectum

Correct answer: C

Rationale: Positioning the client on their left side is crucial when administering an enema as it helps facilitate the flow of the solution into the sigmoid and descending colon. This position allows gravity to assist in the process. Placing the client on the left side is a standard practice to promote optimal outcomes during the procedure. Choices A, B, and D are incorrect. Choice A provides a specific measurement for the insertion depth of the rectal tube, which is not typically necessary to include in the plan of action. Choice B is essential but not specific to enema administration. Choice D mentions holding the solution bag without specifying the correct height, which should typically be around 18-24 inches above the rectum for a cleansing enema.

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