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1. A client with chronic kidney disease needs dietary restrictions. What restriction is necessary?
- A. Increase protein intake
- B. Limit potassium-rich foods
- C. Increase fluid intake to prevent dehydration
- D. Increase phosphorus intake
Correct answer: B
Rationale: The correct answer is to limit potassium-rich foods for clients with chronic kidney disease. Excessive potassium can be harmful to individuals with compromised kidney function, leading to complications. This restriction helps in managing the condition and preventing further health issues. Choice A is incorrect because increasing protein intake can put additional stress on the kidneys. Choice C is incorrect as excessive fluid intake can burden the kidneys. Choice D is incorrect as increasing phosphorus intake can be harmful for individuals with kidney disease.
2. A client who is at 36 weeks of gestation is being taught about nonstress testing. Which of the following statements should the nurse include in the teaching?
- A. This test will determine the length of your cervix.
- B. You will have your blood pressure taken frequently during the test.
- C. You should press the handheld button when you feel your baby move.
- D. This test will take about 5 minutes to complete.
Correct answer: C
Rationale: The correct answer is C. In a nonstress test, the client is required to press a handheld button whenever fetal movement is felt, which is then recorded on the monitor. This action helps assess the baby's heart rate in response to its movements, providing valuable information about the baby's well-being. Choices A, B, and D are incorrect because the nonstress test does not involve determining the length of the cervix, monitoring blood pressure, or being completed in 5 minutes. These aspects are not part of the nonstress testing procedure and are unrelated to the purpose of the test.
3. How should a healthcare professional assess and manage a patient with delirium?
- A. Assess for confusion and reorient the patient
- B. Provide a quiet environment and administer sedatives
- C. Provide oxygen therapy and monitor vital signs
- D. Provide pain relief and monitor for signs of recovery
Correct answer: A
Rationale: The correct way to assess and manage a patient with delirium is by assessing for confusion and reorienting the patient. Delirium is characterized by acute confusion and disturbance in attention, so reorienting the patient to time, place, and person can help improve their awareness and cognition. Providing a quiet environment is important to reduce stimuli that can exacerbate delirium, but administering sedatives may worsen the condition. Oxygen therapy and monitoring vital signs are essential aspects of general patient care but are not specific to managing delirium. Providing pain relief is important for overall patient comfort but may not directly address the core issue of delirium.
4. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?
- A. Use sterile gloves
- B. Lubricate the catheter with water
- C. Insert the catheter using clean technique
- D. Open the catheterization kit away from the body
Correct answer: D
Rationale: The correct action for the nurse to take when preparing to insert an indwelling urinary catheter is to open the catheterization kit away from the body. This is crucial to maintain the sterility of the kit and the procedure. Using sterile gloves (Choice A) is important, but it is not specific to this step. Lubricating the catheter with water (Choice B) is incorrect as it should be lubricated with a water-soluble lubricant. Inserting the catheter using clean technique (Choice C) is incorrect as indwelling urinary catheter insertion requires sterile technique to prevent infections.
5. A nurse is caring for a client who is scheduled for a bronchoscopy. Which of the following findings should the nurse report to the provider?
- A. The client is anxious about the procedure.
- B. The client has not eaten for 8 hours.
- C. The client has a reported allergy to shellfish.
- D. The client has a platelet count of 100,000/mm³.
Correct answer: D
Rationale: The correct answer is D. A platelet count of 100,000/mm³ is low and increases the risk of bleeding during the bronchoscopy. This finding should be reported to the provider for further evaluation and possible intervention. Choices A, B, and C are not as critical in this situation. Anxiety about the procedure is common and can be managed with appropriate interventions. Not eating for 8 hours is a standard pre-procedure requirement to prevent aspiration during sedation. A reported allergy to shellfish is important to note but is not directly related to the risk of complications during a bronchoscopy.
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