Nursing Elites

1. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian.

• A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
• B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
• C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
• D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct answer: C

Rationale: The correct answer is C. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium and water. Therefore, clients on spironolactone should reduce their intake of foods high in potassium to prevent hyperkalemia. Choices A, B, and D are incorrect because limiting spinach intake due to warfarin, eating anchovies with gout, and taking calcium carbonate with water for osteoporosis do not directly relate to the medication's side effects or dietary restrictions associated with spironolactone.

2. A nurse in an emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

• A. Obtain a baseline ECG
• B. Obtain a blood specimen for ABG analysis
• C. Insert an 18-gauge IV catheter
• D. Administer 100% humidified oxygen

Correct answer: D

Rationale: In a client experiencing drooling and hoarseness following a burn injury, the priority action for the nurse is to administer 100% humidified oxygen. This is crucial to maintain the airway and address respiratory distress, which takes precedence over obtaining an ECG, collecting blood for ABG analysis, or inserting an IV catheter. Providing oxygen therapy is essential in ensuring the client's oxygenation and respiratory function are optimized in this emergency situation.

3. A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take?

• A. Provide information about stress management.
• B. Maintain a warm temperature in the client's room.
• C. Administer epinephrine for acute episodes.
• D. Give glucocorticoid steroids twice a day.

Correct answer: A

Rationale: Corrected Rationale: Providing information about stress management is essential when caring for a client with Raynaud's disease because stress can trigger episodes. Stress management techniques can help the client avoid triggers and reduce the frequency of episodes. Choice B is incorrect because maintaining a warm temperature, rather than a cool one, helps prevent vasoconstriction and can be beneficial for clients with Raynaud's disease. Choice C is incorrect because epinephrine is not a standard treatment for Raynaud's disease; it is more commonly used for severe allergic reactions. Choice D is incorrect because glucocorticoid steroids are not typically used in the management of Raynaud's disease.

4. 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.

5. What is the priority nursing intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer bronchodilators
• D. Administer IV fluids

Correct answer: A

Rationale: The correct answer is to administer oxygen. In a patient experiencing respiratory distress, ensuring adequate oxygenation is the priority. Administering oxygen helps improve oxygen levels, which is crucial for the patient's well-being. Repositioning the patient, administering bronchodilators, or giving IV fluids are important interventions in certain situations, but when a patient is in respiratory distress, providing oxygen takes precedence over other actions.

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