Nursing Elites

1. A client with chronic kidney disease is receiving dietary teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will increase my intake of bananas.
• B. I will limit my intake of foods high in potassium.
• C. I will increase my intake of protein-rich foods.
• D. I will increase my intake of dairy products.

Correct answer: B

Rationale: The correct answer is B. Limiting potassium-rich foods is crucial for clients with chronic kidney disease to prevent hyperkalemia, a common complication. Increasing intake of potassium-rich foods like bananas (choice A), protein-rich foods (choice C), or dairy products (choice D) can exacerbate hyperkalemia in these clients. Bananas, protein-rich foods, and dairy products are all high in potassium, which is detrimental for individuals with chronic kidney disease. Therefore, choices A, C, and D are incorrect.

2. A healthcare professional is reviewing the medical record of a client with schizophrenia. Which of the following findings should the professional report to the provider?

• A. Blood pressure: 102/56 mm Hg.
• B. Heart rate: 95/min.
• C. Sore throat.
• D. WBC count 14,000/mm^3.

Correct answer: D

Rationale: An elevated WBC count should be reported to the provider as it may indicate an infection. Elevated white blood cell counts can be a sign of an underlying infection or inflammation. Monitoring and reporting abnormal laboratory values are essential for timely interventions. The other options, such as blood pressure, heart rate, and a sore throat, while important for overall assessment, are not directly related to the potential medical urgency indicated by an elevated WBC count.

3. A client who has a new prescription for lithium is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will need to have my blood levels checked regularly while taking this medication.
• B. I should take this medication on an empty stomach.
• C. I should avoid eating foods that are high in sodium.
• D. I should stop taking this medication if I experience nausea.

Correct answer: A

Rationale: The correct answer is A. Clients prescribed lithium need regular monitoring of blood levels to ensure the medication's effectiveness and safety. This monitoring helps to keep the medication within the therapeutic range and prevent toxicity. Choice B is incorrect because lithium is usually taken with food to minimize gastrointestinal side effects. Choice C is not directly related to lithium therapy; however, excessive sodium intake can affect lithium levels. Choice D is incorrect as abruptly stopping lithium can lead to adverse effects and should only be done under healthcare provider guidance.

4. A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?

• A. Insert the catheter until urine flows, then advance 2.5 to 5 cm (1 to 2 in) further.
• B. Advance the catheter 7.5 to 10 cm (3 to 4 in) after urine begins to flow.
• C. Advance the catheter 17 to 22.5 cm (7 to 9 in) after urine begins to flow.
• D. Advance the catheter 5 to 7.5 cm (2 to 3 in) after urine begins to flow.

Correct answer: C

Rationale: When inserting an indwelling urinary catheter for a male client, it is crucial to advance the catheter 17 to 22.5 cm after urine begins to flow. This helps ensure proper placement in the male urethra, which is longer compared to females. Choice A is incorrect as advancing only 2.5 to 5 cm would not reach the correct placement in male clients. Choice B is incorrect as advancing 7.5 to 10 cm is insufficient to reach the appropriate location in male clients. Choice D is also incorrect as advancing 5 to 7.5 cm would likely not reach the desired placement in male clients.

5. When discussing clients designating a health care proxy in situations requiring a durable power of attorney for health care (DPAHC), what information should the charge nurse include?

• A. The proxy should make health care decisions for the client regardless of the client's ability to do so.
• B. The proxy can make financial decisions if the need arises.
• C. The proxy can make treatment decisions if the client is under anesthesia.
• D. The proxy should manage legal issues for the client.

Correct answer: C

Rationale: The correct answer is C. The charge nurse should include information that the proxy can make treatment decisions if the client is under anesthesia. This is a key function of a durable power of attorney for health care. Choices A, B, and D are incorrect because a health care proxy's role is specifically related to making health care decisions, not financial decisions, legal issues, or decisions made under anesthesia.

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