Nursing Elites

1. A nurse is reinforcing nutrition teaching with a client who has osteoporosis. Which of the following food selections should the nurse recommend to increase calcium in the client's diet?

• A. 1 medium apple
• B. 3 oz of lean beef
• C. 1 tbsp of cream cheese
• D. 1 cup of kale

Correct answer: D

Rationale: The correct answer is D: 1 cup of kale. Kale is rich in calcium, making it a suitable choice to increase calcium intake for individuals with osteoporosis. While fruits like apples (choice A) are nutritious, they are not high in calcium. Lean beef (choice B) is a good source of protein but not a significant source of calcium. Cream cheese (choice C) is also not a primary source of calcium compared to kale.

2. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?

• A. Blood urea nitrogen 50 mg/dl
• B. Hemoglobin of 10.3 g/dl
• C. Venous blood pH 7.30
• D. Serum potassium 6 mEq/L

Correct answer: D

Rationale: A serum potassium level of 6 mEq/L indicates hyperkalemia, which can be life-threatening and requires immediate intervention. Hyperkalemia can lead to dangerous cardiac arrhythmias and must be addressed promptly. The other options are not as urgent. A blood urea nitrogen level of 50 mg/dl may indicate kidney dysfunction but does not require immediate intervention. Hemoglobin of 10.3 g/dl may suggest anemia, which needs management but is not an immediate threat. A venous blood pH of 7.30 may indicate acidosis, which is concerning but not as acutely dangerous as hyperkalemia.

3. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

• A. have the client identify coping methods
• B. get the description of the location and intensity of the pain
• C. accept the client's report of pain
• D. determine the client's status of pain

Correct answer: B

Rationale: The correct answer is B: 'get the description of the location and intensity of the pain.' When a client complains of pain, the initial step in pain assessment is to gather information about the location and intensity of the pain. This helps the nurse understand the nature of the pain and lays the groundwork for further assessment and management. Choice A is incorrect because identifying coping methods comes later in the assessment process. Choice C is incorrect as accepting the client's report of pain is important, but not the first step. Choice D is incorrect as determining the client's pain status also comes after gathering information about the pain.

4. A nurse is reinforcing teaching with a client who has Crohn's Disease and is experiencing frequent cramping and diarrhea. Which of the following statements should the nurse include in the teaching?

• A. Increase your caloric intake by eating foods high in protein.
• B. Include fresh fruits and vegetables at each meal.
• C. Maintain your weight by eating high-fat foods.
• D. Drink whole milk to ensure adequate calcium intake.

Correct answer: A

Rationale: The correct answer is A. Increasing caloric intake by eating foods high in protein can help Crohn's Disease patients maintain their weight and manage symptoms. Choice B is incorrect because fresh fruits and vegetables may exacerbate symptoms due to their high fiber content. Choice C is incorrect as high-fat foods can be difficult to digest and may worsen symptoms. Choice D is incorrect because whole milk can be problematic for individuals with Crohn's Disease due to its high fat content.

5. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is:

• A. difference in the intake and output
• B. changes in the mucous membranes
• C. skin turgor
• D. weekly weight

Correct answer: D

Rationale: In a client with altered renal function, monitoring fluid balance is crucial. Weekly weight is the most accurate indicator of fluid balance during the visits as it reflects cumulative changes in the body's fluid status. Changes in intake and output (Choice A) can provide valuable information, but weekly weight is a more direct measure of overall fluid retention or loss. Changes in mucous membranes (Choice B) and skin turgor (Choice C) can be influenced by factors other than fluid balance, making them less reliable indicators in this context.

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