Nursing Elites

1. A nurse is providing teaching to a client who has a new diagnosis of hypertension. Which of the following dietary recommendations should the nurse include?

• A. Limit sodium intake to 4 grams per day.
• B. Limit protein intake to 80 grams per day.
• C. Limit saturated fat intake to 7% of daily calories.
• D. Limit fluid intake to 1,500 mL per day.

Correct answer: C

Rationale: The correct answer is to limit saturated fat intake to 7% of daily calories. This recommendation is crucial for clients with hypertension to lower cholesterol levels and promote heart health. Choice A, limiting sodium intake to 4 grams per day, is important for hypertension but not the best recommendation compared to limiting saturated fats. Choice B, limiting protein intake to 80 grams per day, is not a primary dietary concern for hypertension. Choice D, limiting fluid intake to 1,500 mL per day, is not a standard recommendation for hypertension management.

2. A client requests the creation of a living will. Which of the following actions should the nurse take?

• A. Schedule a meeting between the hospital ethics committee and the client
• B. Evaluate the client's understanding of life-sustaining measures
• C. Determine the client's preferences about post-mortem care
• D. Request a conference with the client's family

Correct answer: B

Rationale: The correct action for the nurse to take when a client requests the creation of a living will is to evaluate the client's understanding of life-sustaining measures. This step is crucial to ensure that the client is well-informed about their options before making decisions regarding their future care. Scheduling a meeting with the hospital ethics committee (choice A) may not be necessary at this stage and could overwhelm the client. Determining the client's preferences about post-mortem care (choice C) is not directly related to creating a living will. Requesting a conference with the client's family (choice D) may be important later but is not the initial step in this situation.

3. While caring for a newborn with jaundice receiving phototherapy, what action should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head covered with a cap.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take while caring for a newborn with jaundice receiving phototherapy is to ensure that the newborn wears a diaper. This is essential to prevent skin irritation during phototherapy. Feeding the infant glucose water or applying lotion are not pertinent to managing jaundice or phototherapy. Keeping the infant's head covered with a cap is also not necessary for this specific situation.

4. A nurse is assessing a client who is receiving digoxin for heart failure. Which of the following findings should the nurse report to the provider?

• A. Heart rate 68/min.
• B. Blood pressure 110/70 mm Hg.
• C. Vision changes.
• D. Respiratory rate 18/min.

Correct answer: C

Rationale: Corrected Rationale: Vision changes are a common sign of digoxin toxicity, which can be serious and should be reported to the provider immediately. Changes in heart rate, blood pressure, or respiratory rate are not typically associated with digoxin toxicity. Therefore, the nurse should prioritize reporting vision changes to ensure prompt assessment and intervention.

5. A client is receiving continuous IV nitroprusside for severe hypertension. Which action should the nurse take?

• A. Keep calcium gluconate at the bedside.
• B. Monitor blood pressure every 2 hours.
• C. Limit IV exposure to light.
• D. Attach an inline filter to the IV tubing.

Correct answer: C

Rationale: The correct action for the nurse to take is to limit IV exposure to light. Nitroprusside is light-sensitive, and exposure to light can lead to its degradation, potentially reducing its efficacy in treating severe hypertension. Keeping calcium gluconate at the bedside (Choice A) is not directly related to managing nitroprusside infusion. While monitoring blood pressure every 2 hours (Choice B) is important in managing hypertension, it is not the immediate action required to ensure medication efficacy. Attaching an inline filter to the IV tubing (Choice D) may help filter particles but does not address the critical concern of light sensitivity associated with nitroprusside administration.

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