Nursing Elites

1. A nurse is planning care for an adolescent client with chronic renal failure. Which action should the nurse include?

• A. Encourage a diet high in calcium
• B. Provide a diet high in potassium
• C. Ensure increased fluid intake
• D. Restrict protein intake to the RDA

Correct answer: D

Rationale: In chronic renal failure, it is essential to restrict protein intake to the Recommended Dietary Allowance (RDA) to reduce the accumulation of waste products that the kidneys can no longer effectively eliminate. Choices A, B, and C are incorrect because in chronic renal failure, high calcium, high potassium, and increased fluid intake can further strain the kidneys and worsen the condition.

2. A nurse is providing discharge teaching for a client newly prescribed methadone. Which statement indicates a need for further teaching?

• A. I understand methadone slows my breathing.
• B. I understand methadone may cause me to have trouble sleeping.
• C. I will avoid alcohol while taking this medication.
• D. I’ll change positions slowly to prevent dizziness.

Correct answer: B

Rationale: The correct answer is B. Trouble sleeping is not a typical side effect of methadone; the nurse should clarify this misunderstanding. Choices A, C, and D are all correct statements regarding methadone. Methadone can indeed slow breathing, so it is important for the client to be aware of this effect. Avoiding alcohol while taking methadone is crucial due to the increased risk of central nervous system depression when alcohol is combined with methadone. Additionally, changing positions slowly can help prevent dizziness, which can be a side effect of methadone.

3. When a nurse is interviewing a client who is requesting oral contraceptives, which finding in the client’s history is a contraindication to combined oral contraceptives?

• A. Thyroid disease
• B. Allergy to penicillin
• C. Impaired liver function
• D. Abnormal blood glucose levels

Correct answer: C

Rationale: The correct answer is C: Impaired liver function. Impaired liver function is a contraindication to the use of oral contraceptives because they are metabolized in the liver. Choices A, B, and D are incorrect. Thyroid disease, allergy to penicillin, and abnormal blood glucose levels are not contraindications to combined oral contraceptives.

4. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

• A. Inspect the pin site every 4 hours
• B. Monitor the client’s skin under the halo vest
• C. Ensure two personnel hold the halo device when repositioning the client
• D. Apply powder frequently to the client’s skin under the vest to decrease itching

Correct answer: B

Rationale: The correct answer is to monitor the client’s skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because inspecting the pin site every 4 hours is necessary but not the priority in this case. Choice C is incorrect as it is not essential for two personnel to hold the halo device during repositioning. Choice D is incorrect because applying powder frequently can actually increase the risk of skin issues by clogging pores and causing irritation.

5. A nurse is assessing a client for signs of allergic reaction. Which of the following should the nurse look for?

• A. Fever
• B. Rash
• C. Fatigue
• D. Increased appetite

Correct answer: B

Rationale: Correct! When assessing a client for signs of an allergic reaction, a nurse should look for a rash. A rash is a common manifestation of an allergic response, such as contact dermatitis or hives. It is important to recognize and assess rashes promptly as they can indicate an allergic reaction.\nOption A, fever, is not typically a primary sign of an allergic reaction but may occur in severe cases. Option C, fatigue, is a general symptom and not specific to allergic reactions. Option D, increased appetite, is not a common sign of an allergic reaction and is more likely related to other conditions or factors.

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