Nursing Elites

1. A client receives education on dietary management for ulcerative colitis from a nurse. Which of the following statements should the nurse include in the teaching?

• A. You should increase your intake of high-fiber foods.
• B. You should avoid foods containing lactose.
• C. You should decrease your intake of dairy products.
• D. You should increase your intake of dairy products.

Correct answer: C

Rationale: The correct statement the nurse should include in the teaching is to decrease the intake of dairy products. This is because reducing the intake of dairy products is beneficial in managing symptoms of ulcerative colitis. Dairy products can aggravate symptoms due to their lactose content, thus advising the client to decrease their consumption can help alleviate discomfort and promote better management of the condition.\nChoice A is incorrect because increasing high-fiber foods may worsen symptoms in some individuals with ulcerative colitis.\nChoice B is incorrect as while it is advised to avoid foods containing lactose, this alone does not encompass the full dietary management for ulcerative colitis.\nChoice D is incorrect as increasing the intake of dairy products can exacerbate symptoms in individuals with ulcerative colitis due to their lactose content.

2. When admitting a client at risk for falls in a long-term care facility, what should the nurse do first?

• A. Complete a fall-risk assessment
• B. Place a fall-risk identification bracelet on the client
• C. Provide the client with nonskid footwear
• D. Set the bed to the lowest position

Correct answer: A

Rationale: The initial step in caring for a client at risk for falls is to conduct a fall-risk assessment. This assessment helps the nurse gather crucial data to identify specific risks and individualized needs, guiding subsequent interventions and preventive measures. By completing a thorough assessment, the nurse can develop a targeted plan of care to mitigate fall risk and ensure the client's safety. Placing a fall-risk identification bracelet, providing nonskid footwear, or setting the bed to the lowest position may be important interventions, but these actions should be based on the findings of the fall-risk assessment, making choice A the priority.

3. When preparing to insert an NG tube for a client who requires gastric decompression, which of the following actions should the nurse take?

• A. Position the client with the head of the bed elevated to 30° prior to insertion
• B. Measure the tube from the client's nose to the earlobe to the xiphoid process
• C. Lubricate the entire length of the tube with water-soluble lubricant
• D. Instruct the client to cough during insertion

Correct answer: B

Rationale: Measuring the tube from the client's nose to the earlobe to the xiphoid process ensures the tube is inserted to the correct depth. This measurement helps prevent complications such as tube misplacement or lung insertion. Positioning the client with the head of the bed elevated to 30° is important to facilitate easier insertion but is not the most crucial step. Lubricating the entire length of the tube with water-soluble lubricant is essential for smooth insertion but is not the most critical action. Instructing the client to cough during insertion is not necessary and may lead to unnecessary discomfort.

4. A client has a new prescription for furosemide. Which of the following instructions should the nurse include during discharge teaching?

• A. Avoid foods high in potassium.
• B. Monitor weight daily.
• C. Take the medication with food.
• D. Increase salt intake.

Correct answer: B

Rationale: Monitoring weight daily is crucial when taking furosemide to detect fluid retention or loss. Furosemide is a diuretic that helps the body get rid of excess water and salt through urine. Changes in weight can indicate fluid shifts, which could be a sign of inadequate response to the medication or worsening condition. Therefore, monitoring weight daily is essential to assess the effectiveness of furosemide therapy and detect any potential issues early on. Choices A, C, and D are incorrect. Avoiding foods high in potassium is more relevant for clients taking potassium-sparing diuretics, not furosemide. Taking furosemide with food is not necessary, as it can be taken with or without food. Increasing salt intake is contradictory to the purpose of furosemide, which aims to eliminate excess salt from the body.

5. A client has a new diagnosis of nephrotic syndrome, and the nurse is providing dietary management education. Which of the following statements should the nurse include in the teaching?

• A. You should increase your intake of high-sodium foods.
• B. You should decrease your intake of high-sodium foods.
• C. You should avoid foods that contain lactose.
• D. You should increase your intake of dairy products.

Correct answer: B

Rationale: For a client with nephrotic syndrome, decreasing the intake of high-sodium foods is essential to manage fluid retention and symptoms of the condition. Excessive sodium can lead to fluid retention, swelling, and worsen the condition. Therefore, advising the client to decrease their high-sodium food intake aligns with the dietary management approach to help control nephrotic syndrome. Choices A, C, and D are incorrect. Increasing high-sodium foods would exacerbate fluid retention, avoiding lactose is not specifically required for nephrotic syndrome, and increasing dairy products may not be necessary unless individualized based on the client's needs and lab values.

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