Nursing Elites

1. The client with congestive heart failure has been educated about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?

• A. Cheese sandwich with a glass of 2% milk
• B. Sliced turkey sandwich and canned pineapple
• C. Cheeseburger and baked potato
• D. Mushroom pizza and ice cream

Correct answer: B

Rationale: The correct answer is B: Sliced turkey sandwich and canned pineapple. This lunch choice is suitable for a client with congestive heart failure as it is low in sodium. Sliced turkey is a lean protein choice, and canned pineapple is a low-sodium fruit option. Choice A contains high-sodium items like cheese and 2% milk. Choice C includes a cheeseburger, which is typically high in sodium, and a baked potato could also be high in sodium depending on preparation. Choice D consists of mushroom pizza and ice cream, both of which can be high in sodium, especially in processed or restaurant-prepared forms.

2. Which client calling the community health clinic would the nurse ask to come in that day to be seen by the health care provider?

• A. I started my period, and now my urine has turned bright red.
• B. I am a diabetic, and today I have been going to the bathroom every hour.
• C. I was started on medicine yesterday for a urinary infection. Now my lower belly hurts when I go to the bathroom.
• D. I went to the bathroom, and my urine looked very red, and it didn't hurt when I went.

Correct answer: D

Rationale: The correct answer is D because bright red urine without pain suggests possible hematuria, which is a concerning symptom that requires immediate medical evaluation. Option A mentions bright red urine but also relates it to starting a period, which is less likely to be an urgent issue. Option B describes increased urination, which may indicate hyperglycemia but doesn't require immediate evaluation. Option C presents symptoms more related to a urinary tract infection that may not require urgent attention.

3. Which of these nursing assessments would be the highest priority for a client at risk for aspiration pneumonia?

• A. Assessing the client's level of consciousness
• B. Monitoring the client's oxygen saturation
• C. Checking the client's gag reflex before eating or drinking
• D. Monitoring the client's intake and output

Correct answer: C

Rationale: Checking the client's gag reflex before eating or drinking is the highest priority for a client at risk for aspiration pneumonia. Aspiration pneumonia can occur when food, liquids, or saliva are inhaled into the lungs, leading to inflammation or infection. Checking the gag reflex helps prevent the aspiration of substances into the lungs. Assessing the client's level of consciousness (Choice A) is important but not as immediately critical as checking the gag reflex. Monitoring oxygen saturation (Choice B) is essential for respiratory assessment but does not directly prevent aspiration. Monitoring intake and output (Choice D) is important for overall client management but does not specifically address the risk of aspiration pneumonia.

4. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?

• A. As you urinate more, you will need less medication to control fluid.
• B. You will have to take this medication for about a year.
• C. The medication must be continued so the fluid problem is controlled.
• D. Please talk to your health care provider about medications and treatments.

Correct answer: C

Rationale: Diuretics must be continued to control fluid retention, as stopping them can lead to worsening of congestive heart failure.

5. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?

• A. Blood urea nitrogen 50 mg/dl
• B. Hemoglobin of 10.3 g/dl
• C. Venous blood pH 7.30
• D. Serum potassium 6 mEq/L

Correct answer: D

Rationale: A serum potassium level of 6 mEq/L indicates hyperkalemia, which can be life-threatening and requires immediate intervention. Hyperkalemia can lead to dangerous cardiac arrhythmias and must be addressed promptly. The other options are not as urgent. A blood urea nitrogen level of 50 mg/dl may indicate kidney dysfunction but does not require immediate intervention. Hemoglobin of 10.3 g/dl may suggest anemia, which needs management but is not an immediate threat. A venous blood pH of 7.30 may indicate acidosis, which is concerning but not as acutely dangerous as hyperkalemia.

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