Nursing Elites

1. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:

• A. A ham and Swiss cheese sandwich on whole wheat bread
• B. Mashed potatoes and broiled chicken
• C. A tossed salad with oil and vinegar and olives
• D. Chicken bouillon

Correct answer: B

Rationale: The correct answer is B: Mashed potatoes and broiled chicken. Both mashed potatoes and broiled chicken are typically low in sodium content, making them suitable choices for a 500-mg low sodium diet. The other options, such as a ham and Swiss cheese sandwich on whole wheat bread, a tossed salad with oil and vinegar and olives, and chicken bouillon, may contain higher amounts of sodium and are not typically recommended for a low sodium diet.

2. A client is being assessed by a nurse who is 30 minutes postoperative following an arterial thrombectomy. Which of the following findings should the nurse report?

• A. Chest pain
• B. Muscle spasms
• C. Cool, moist skin
• D. Incisional pain

Correct answer: A

Rationale: Chest pain is a critical finding postoperatively, especially after an arterial thrombectomy, as it could indicate complications like myocardial infarction or pulmonary embolism. It requires immediate attention and further evaluation. Muscle spasms, cool moist skin, and incisional pain are important to assess but not as urgent as chest pain in this scenario.

3. A group of clients are being educated about influenza. Which of the following client statements indicates an understanding of the teaching?

• A. ''I should wash my hands after blowing my nose to prevent spreading the virus.''
• B. ''I need to avoid drinking fluids if I develop symptoms.''
• C. ''I need a flu shot every 2 years because of the different flu strains.''
• D. ''I should cover my mouth with my hand when I sneeze.''

Correct answer: A

Rationale: The correct answer is, 'I should wash my hands after blowing my nose to prevent spreading the virus.' This statement shows understanding of the importance of hand hygiene in preventing the spread of influenza. Washing hands after activities like blowing the nose can help reduce the risk of transmitting the virus to others. Choices B, C, and D are incorrect as they do not reflect accurate understanding of influenza prevention measures.

4. A client is to receive thrombolytic therapy. Which of the following factors should be recognized as a contraindication to the therapy?

• A. Hip arthroplasty 2 weeks ago
• B. Elevated sedimentation rate
• C. Incident of exercise-induced asthma 1 week ago
• D. Elevated platelet count

Correct answer: A

Rationale: Thrombolytic therapy involves the use of medications to dissolve blood clots. Hip arthroplasty (joint replacement surgery) performed recently is a contraindication to thrombolytic therapy due to the risk of bleeding. Elevated sedimentation rate, exercise-induced asthma, and elevated platelet count are not contraindications to thrombolytic therapy.

5. A 38-year-old patient’s vital signs at 8 a.m. are axillary temperature 99.6°F (37.6°C); pulse rate 88; respiratory rate 30. Which findings should be reported?

• A. Respiratory rate only
• B. Temperature only
• C. Pulse rate and temperature
• D. Temperature and respiratory rate

Correct answer: D

Rationale: Both an elevated temperature and an increased respiratory rate are abnormal vital signs that could indicate an underlying health issue. Reporting both of these findings is crucial to ensure appropriate evaluation and intervention if needed.

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