Nursing Elites

1. 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.

2. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?

• A. The tube will drain fluid from your chest.
• B. The tube will remove excess air from your chest.
• C. The tube controls the amount of air that enters your chest.
• D. The tube will seal the hole in your lung.

Correct answer: B

Rationale: The correct answer is B: 'The tube will remove excess air from your chest.' In a spontaneous pneumothorax, air accumulates in the pleural space, causing lung collapse. The chest tube is inserted to remove this excess air, allowing the lung to re-expand. Choices A, C, and D are incorrect because the primary purpose of a chest tube in pneumothorax is to evacuate air, not fluid, control air entry, or seal a lung hole.

3. Which information is a priority for the client to reinforce after intravenous pyelography?

• A. Eat a light diet for the rest of the day
• B. Rest for the next 24 hours as the preparation and test are tiring.
• C. During waking hours, drink at least 1 8-ounce glass of fluid every hour for the next 2 days
• D. Measure urine output for the next day and immediately notify the healthcare provider if it decreases.

Correct answer: D

Rationale: After intravenous pyelography, monitoring urine output is crucial to assess kidney function and detect any early signs of complications. Decreased urine output could indicate a problem with kidney function or potential complications from the procedure. While rest and hydration are important, the priority lies in monitoring urine output for any abnormalities. Eating a light diet may be recommended, but it is not the priority post-procedure instruction.

4. A client is receiving intravenous antibiotics for the treatment of a severe infection. Which of these assessments is a priority for the nurse to perform?

• A. Monitor the client's temperature
• B. Assess the client's pain level
• C. Check the intravenous (IV) site for signs of phlebitis
• D. Monitor the client's respiratory status

Correct answer: C

Rationale: When a client is receiving intravenous antibiotics, checking the IV site for signs of phlebitis is a priority assessment for the nurse. Phlebitis is an inflammation of the vein, which can lead to serious complications such as infection and thrombosis. Monitoring the IV site helps prevent these complications and ensures the safe delivery of antibiotics. While monitoring the client's temperature, pain level, and respiratory status are important assessments, they are not the priority in this scenario where IV antibiotic administration requires close monitoring for complications like phlebitis.

5. After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate?

• A. 3 oz. broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
• B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
• C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
• D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

Correct answer: D

Rationale: The most appropriate meal plan for a client following a myocardial infarction and placed on a sodium-restricted diet should include fresh ingredients with low sodium content to promote heart health. Option D, which consists of 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange, aligns best with these requirements. Option A contains canned beets, which are typically high in sodium. Option B includes canned salmon, which may have added sodium. Option C has a bologna sandwich, which is processed and high in sodium. Therefore, Option D is the most suitable choice for a client needing a low-sodium diet after a heart attack.

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