Nursing Elites

1. A nurse is teaching a client who has ulcerative colitis about dietary recommendations. Which of the following instructions should the nurse include?

• A. Avoid high-fiber foods
• B. Increase intake of spicy foods
• C. Consume foods high in fiber
• D. Eat large, infrequent meals

Correct answer: C

Rationale: The correct answer is C: 'Consume foods high in fiber.' Consuming high-fiber foods helps manage symptoms of ulcerative colitis by promoting regular bowel movements. Choices A, B, and D are incorrect. Avoiding high-fiber foods can worsen symptoms as fiber is beneficial for digestive health. Increasing the intake of spicy foods can exacerbate inflammation in the digestive tract, leading to more discomfort. Eating large, infrequent meals can put more strain on the digestive system, which is not ideal for managing ulcerative colitis.

2. What is the priority nursing action for a dehydrated client who needs fluids?

• A. Administer antiemetics to prevent vomiting
• B. Monitor electrolyte levels frequently
• C. Administer oral rehydration solutions
• D. Insert an NG tube for fluid administration

Correct answer: B

Rationale: The correct answer is to monitor electrolyte levels frequently. When a client is dehydrated and needs fluids, it is essential to monitor electrolyte levels to prevent complications such as electrolyte imbalances. Administering antiemetics to prevent vomiting (Choice A) may be necessary but is not the priority when addressing dehydration. Administering oral rehydration solutions (Choice C) can be beneficial, but monitoring electrolyte levels takes precedence to ensure proper hydration. Inserting an NG tube for fluid administration (Choice D) is invasive and not typically the first-line approach for managing dehydration.

3. How should a healthcare provider manage a patient with hyperkalemia?

• A. Administer insulin and glucose
• B. Restrict potassium intake
• C. Monitor ECG
• D. All of the above

Correct answer: D

Rationale: In managing hyperkalemia, it is essential to administer insulin and glucose to shift potassium into the cells, restrict potassium intake to prevent further elevation of serum levels, and monitor the ECG for signs of potassium-induced cardiac effects. Therefore, the correct answer is D, as all of the provided actions are important in the management of hyperkalemia. Choice A alone is not sufficient as it only addresses shifting potassium intracellularly without preventing further elevation. Choice B alone is not enough as it does not address the immediate need to lower serum potassium levels. Choice C alone is insufficient as it only monitors for cardiac effects without addressing potassium levels or shifting mechanisms.

4. What should a person recommend to a client experiencing constipation?

• A. Increase fluid intake to prevent further dehydration
• B. Increase dietary fiber to promote regular bowel movements
• C. Administer a laxative to relieve constipation
• D. Encourage bed rest to allow for bowel function to return

Correct answer: B

Rationale: Increasing dietary fiber is an effective recommendation for clients experiencing constipation as it helps promote regular bowel movements. Choice A, increasing fluid intake, is also important but the most appropriate initial recommendation for constipation is to increase dietary fiber. Choice C, administering a laxative, should not be the first-line recommendation and is typically considered after dietary and lifestyle interventions. Choice D, encouraging bed rest, does not directly address constipation relief or prevention.

5. What are the nursing interventions for a patient with a pressure ulcer?

• A. Clean the wound and apply a hydrocolloid dressing
• B. Provide a high-protein diet and ensure bed rest
• C. Monitor for signs of infection and provide antibiotics
• D. Provide a low-sodium diet and monitor for fluid retention

Correct answer: A

Rationale: The correct nursing intervention for a patient with a pressure ulcer is to clean the wound and apply a hydrocolloid dressing. This promotes healing by creating a moist environment conducive to the wound healing process. Choice B is incorrect because while nutrition is important for wound healing, a high-protein diet alone is not a specific intervention for a pressure ulcer. Choice C is incorrect as antibiotics are only used if there is an infection present. Choice D is also incorrect as a low-sodium diet and monitoring for fluid retention are more related to conditions like heart failure or kidney disease, not specifically pressure ulcer care.

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