Nursing Elites

1. For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?

• A. Ensure that the bed linen is always dry
• B. Frequently check the bed for wetness and keep it dry
• C. Place a rubber sheet under the client's buttocks
• D. Keep the patient clean and dry

Correct answer: A

Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.

2. A nurse is reinforcing dietary teaching with a client who has vitamin A deficiency. Which of the following food choices should the nurse recommend as the best source of vitamin A?

• A. 1 small baked sweet potato
• B. 1 cup avocado
• C. 1 cup green beans
• D. 1 large apple

Correct answer: A

Rationale: The correct answer is A. Sweet potatoes are rich in beta-carotene, which the body converts into vitamin A, essential for vision and immune function. Avocado (choice B) is a good source of healthy fats but not high in vitamin A. Green beans (choice C) are nutritious but not a significant source of vitamin A. Apples (choice D) are low in vitamin A compared to sweet potatoes.

3. What instruction should a nurse include when teaching a client who has recently been prescribed a low-sodium diet?

• A. Avoid foods such as smoked meats and frozen dinners.
• B. Select foods with less than 4g of sodium as indicated on food labels.
• C. Use soy sauce for flavoring foods instead of table salt.
• D. Processed and prepared foods are typically low in sodium.

Correct answer: A

Rationale: The correct answer is A, which directs the client to avoid foods such as smoked meats and frozen dinners. These types of foods are typically high in sodium, making them unsuitable for a low-sodium diet. Option B is incorrect because foods with less than 4g of sodium might still be high in sodium for individuals on low-sodium diets. The daily recommended intake of sodium for a low-sodium diet is usually around 1.5g to 2g. Hence, 4g of sodium in a single food product can be excessive. Option C is incorrect as soy sauce, although a different source of flavor, is also high in sodium and should be used sparingly, if at all, in a low-sodium diet. Option D is incorrect because processed and prepared foods are usually not low in sodium. In fact, these foods often have high sodium content due to added salts and preservatives.

4. After consuming a meal high in fat, the _____ releases _______ to aid in digestion.

• A. stomach, acid
• B. liver, bile
• C. pancreas, bicarbonate
• D. gallbladder, bile

Correct answer: D

Rationale: The gallbladder releases bile into the small intestine to help digest fats. Bile emulsifies fats, breaking them down into smaller droplets for easier digestion. The stomach primarily releases gastric acid, the liver produces bile but stores it in the gallbladder, and the pancreas secretes bicarbonate to neutralize stomach acid in the small intestine. Therefore, choices A, B, and C are incorrect.

5. To raise HDL levels, what is Mrs. Smith advised to do?

• A. quit smoking
• B. increase dietary sodium
• C. take iron supplements
• D. avoid dairy products

Correct answer: A

Rationale: The correct answer is A: quit smoking. Smoking lowers HDL levels, so quitting smoking is crucial to raising HDL levels. Increasing dietary sodium (choice B) is not linked to raising HDL levels and can have negative effects on cardiovascular health. Taking iron supplements (choice C) is not directly related to increasing HDL levels. Avoiding dairy products (choice D) is not necessary to raise HDL levels; in fact, some dairy products like low-fat options can be part of a heart-healthy diet.

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