Nursing Elites

1. A client with hypertension taking a potassium-wasting diuretic is being educated about nutrition by a nurse. Which of the following dietary instructions should the nurse include in the teaching?

• A. Increase consumption of tuna and salmon.
• B. Limit intake of dried fruits.
• C. Avoid cow's milk.
• D. Consume organs and bananas

Correct answer: D

Rationale: The correct answer is D: 'Consume organs and bananas.' When a client is taking a potassium-wasting diuretic, they are at risk of potassium loss. Consuming foods high in potassium, such as organs and bananas, can help counteract this loss. Choice A is incorrect because tuna and salmon are not particularly high in potassium. Choice B is incorrect because dried fruits are good sources of potassium. Choice C is incorrect as cow's milk is also a good source of potassium, which could be beneficial for a client taking a potassium-wasting diuretic.

2. A client is admitted for first and second degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be

• A. Cover the areas with dry sterile dressings
• B. Assess for dyspnea or stridor
• C. Initiate intravenous therapy
• D. Administer pain medication

Correct answer: B

Rationale: The correct answer is to assess for dyspnea or stridor. In burn cases involving the face, neck, or chest, there is a risk of airway compromise due to swelling. Dyspnea (difficulty breathing) or stridor (noisy breathing) can indicate airway obstruction or respiratory distress, which requires immediate intervention. Covering the burns with dry sterile dressings (choice A) can be important but ensuring airway patency takes precedence. Initiating intravenous therapy (choice C) may be necessary but not the priority over assessing the airway. Administering pain medication (choice D) is important for comfort but should come after ensuring the airway is clear and breathing is adequate.

3. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

• A. Add a thickening agent to the fluids
• B. Check the client's gag reflex
• C. Feed the client only solid foods
• D. Increase the rate of intravenous fluids

Correct answer: B

Rationale: Checking the client's gag reflex is the appropriate action in this scenario. It helps assess the client's ability to swallow safely without the risk of aspiration. Adding a thickening agent to the fluids (Choice A) may be considered later if swallowing difficulties persist. Feeding the client only solid foods (Choice C) can increase the risk of aspiration in this case, and increasing the rate of intravenous fluids (Choice D) does not address the swallowing concern.

4. Which statement best describes the effects of immobility in children?

• A. Immobility prevents the progression of language and fine motor development
• B. Immobility in children has similar physical effects to those found in adults
• C. Children are more susceptible to the effects of immobility than adults are
• D. Children are likely to have prolonged immobility with subsequent complications

Correct answer: B

Rationale: The correct answer is B. Immobility in children indeed has physical effects similar to those found in adults. However, it can also significantly impact their development and growth. Choice A is incorrect because immobility does not solely prevent language and fine motor development but affects various aspects. Choice C is incorrect as susceptibility to the effects of immobility may vary between children and adults depending on individual factors. Choice D is incorrect as not all children are likely to have prolonged immobility with subsequent complications.

5. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to

• A. Wrap the leg with elastic bandages
• B. Apply pressure at the bleeding site
• C. Reinforce the dressing and elevate the leg
• D. Remove the dressings and re-dress the incision

Correct answer: B

Rationale: In this scenario where the upper leg dressing becomes saturated with blood post-femoral popliteal bypass, the nurse's first action should be to apply pressure at the bleeding site. Applying pressure is essential to control hemorrhage and prevent further blood loss. Choice A is incorrect as wrapping the leg with elastic bandages would not address the immediate issue of controlling the bleeding. Choice C is incorrect because reinforcing the dressing and elevating the leg should come after controlling the bleeding. Choice D is incorrect as removing the dressings and re-dressing the incision should only be done after the bleeding is under control to prevent excessive blood loss.

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