Nursing Elites

1. A nurse is teaching a client about dietary modifications for a low-sodium diet. Which of the following should the nurse include?

• A. Limit intake of processed foods
• B. Increase intake of fresh fruits and vegetables
• C. Use of accessory muscles
• D. Monitor for allergic reactions

Correct answer: A

Rationale: The correct answer is to limit intake of processed foods. Processed foods are often high in sodium, which goes against the goal of a low-sodium diet. Fresh fruits and vegetables are recommended for a low-sodium diet due to their natural low sodium content. The use of accessory muscles and monitoring for allergic reactions are not related to dietary modifications for a low-sodium diet.

2. A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates a need for further teaching?

• A. I will take ibuprofen for headaches.
• B. I will use an electric razor to shave.
• C. I will avoid eating large amounts of leafy green vegetables.
• D. I will have my blood levels checked regularly.

Correct answer: A

Rationale: The correct answer is A. Ibuprofen can increase the risk of bleeding when taken with warfarin, as both medications affect clotting. The client should use alternative pain relievers like acetaminophen. Choice B is correct as using an electric razor is a safe choice to prevent cuts that could lead to bleeding. Choice C is correct as warfarin interacts with vitamin K found in leafy green vegetables. Choice D is correct as regular blood level checks are necessary to monitor the effects and adjust the warfarin dosage if needed.

3. A nurse is teaching postoperative care to the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching?

• A. Provide an orthodontic pacifier for comfort
• B. Offer fluids using a straw
• C. Cleanse the suture line with a cotton-tip swab
• D. Remove elbow splints periodically to perform range of motion

Correct answer: D

Rationale: The correct answer is D. Elbow splints are utilized to prevent the child from touching the surgical site. However, it is essential to remove them periodically to conduct range-of-motion exercises to prevent joint stiffness. Choices A, B, and C are incorrect because providing an orthodontic pacifier, offering fluids using a straw, and cleansing the suture line with a cotton-tip swab are not directly related to postoperative care following a cleft palate repair.

4. A home health nurse is carefully planning care for a client with Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

• A. Place a daily calendar in the kitchen
• B. Replace buttoned clothing with zippered items
• C. Replace carpet with hardwood floors
• D. Create variation in the daily routine

Correct answer: A

Rationale: Placing a daily calendar in the kitchen is essential for clients with Alzheimer's disease as it helps in orienting them to time and day, providing structure, and minimizing confusion in their daily routine. This action supports cognitive function and independence. Choice B is incorrect as it does not directly address cognitive orientation. Choice C is not a priority in the care plan and may not significantly impact the client's daily functioning. Choice D, creating variation in the daily routine, can actually increase confusion and anxiety in clients with Alzheimer's disease who thrive on predictability and structure.

5. A nurse is planning to administer an injection of morphine to a client. Which of the following actions should the nurse take to ensure client safety?

• A. Instruct the client to take a deep breath during administration.
• B. Administer the medication over 30 seconds.
• C. Verify the client’s pain level.
• D. Have naloxone available in case of respiratory depression.

Correct answer: D

Rationale: The correct answer is to have naloxone available in case of respiratory depression. Morphine is an opioid that can lead to respiratory depression, especially in higher doses. Naloxone is the antidote for opioid overdose and should be readily accessible when administering morphine to reverse respiratory depression if it occurs. Instructing the client to take a deep breath during administration (choice A) is not directly related to ensuring safety in this scenario. Administering the medication over 30 seconds (choice B) may help with the comfort of the client but does not address the potential risk of respiratory depression. Verifying the client's pain level (choice C) is important but not the primary action to ensure safety when administering morphine.

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