Nursing Elites

1. A nurse is providing teaching to a client who has osteoporosis. Which of the following instructions should the nurse include?

• A. Take a calcium supplement once daily.
• B. Walk for 30 minutes three times per week.
• C. Avoid weight-bearing exercises.
• D. Increase intake of vitamin D.

Correct answer: B

Rationale: The correct answer is B. Walking regularly is beneficial for clients with osteoporosis as it helps maintain bone density and prevent fractures. Choice A is not the most appropriate because clients with osteoporosis often require more than just calcium supplements. Choice C is incorrect as weight-bearing exercises actually help strengthen bones. Choice D is important, but walking regularly has a more direct impact on bone health in clients with osteoporosis.

2. A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?

• A. Increased hoarseness
• B. Serum calcium level of 8.0 mg/dL
• C. Respiratory rate of 18/min
• D. Urinary output of 60 mL in 2 hours

Correct answer: B

Rationale: The correct answer is B: 'Serum calcium level of 8.0 mg/dL.' A low serum calcium level indicates hypocalcemia, which is a potential complication of thyroidectomy that can lead to life-threatening consequences, such as tetany or laryngospasm. Therefore, it is crucial for the nurse to report this finding promptly to the provider for timely intervention. Choices A, C, and D are important assessments following a thyroidectomy but are not as critical as detecting and addressing hypocalcemia, which can have serious implications for the client's health.

3. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

• A. Position the client on their left side.
• B. Insert the enema tubing 8 cm (3.1 in) into the client's rectum.
• C. Hold the container of the enema solution 61 cm (24 in) above the client.
• D. Advance the enema tubing 15 cm (6 in) into the client's rectum.

Correct answer: C

Rationale: The correct action the nurse should take when administering a cleansing enema is to hold the container of the enema solution 61 cm (24 in) above the client. This height facilitates the proper flow of the solution into the client's rectum. Positioning the client on their left side helps facilitate the administration process, but it is not the specific action related to the enema solution. Inserting the enema tubing 8 cm (3.1 in) into the rectum is incorrect as it may not deliver the solution effectively. Advancing the enema tubing 15 cm (6 in) into the client's rectum is excessive and could cause trauma.

4. A client is experiencing an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take?

• A. Encourage the client to increase dietary fiber.
• B. Maintain the client on a low-residue diet.
• C. Provide the client with frequent high-calorie snacks.
• D. Encourage the client to eat a high-fiber diet.

Correct answer: B

Rationale: During an acute exacerbation of Crohn's disease, the nurse should maintain the client on a low-residue diet. This diet helps to minimize bowel irritation by reducing the volume and frequency of stools. Choices A, C, and D are incorrect. Encouraging the client to increase dietary fiber (Choice A) and eat a high-fiber diet (Choice D) can worsen symptoms and aggravate bowel inflammation in Crohn's disease. Providing the client with frequent high-calorie snacks (Choice C) may not be appropriate during an exacerbation since high-fat foods can be harder to digest and may exacerbate symptoms.

5. A nurse is assessing a client who has cirrhosis. Which of the following findings should the nurse expect?

• A. Clay-colored stools.
• B. Hypertension.
• C. Stridor.
• D. Elevated temperature.

Correct answer: A

Rationale: Clay-colored stools are a classic finding in a client with cirrhosis. Cirrhosis can lead to impaired bile flow, resulting in pale or clay-colored stools due to a lack of bilirubin in the stool. Hypertension, stridor, and elevated temperature are not typically associated with cirrhosis. Hypertension may occur in cirrhosis but is not a consistent finding, stridor is more commonly associated with upper airway obstruction, and elevated temperature may indicate an infection rather than a direct result of cirrhosis.

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