Nursing Elites

1. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention?

• A. Pallor
• B. Increased temperature
• C. Dyspnea
• D. Involuntary muscle spasms

Correct answer: C

Rationale: Dyspnea indicates a potential complication such as pneumothorax or incorrect catheter placement, requiring immediate attention. Pallor may indicate anemia but is not as urgent as dyspnea in this context. Increased temperature could be a sign of infection but is not as critical as respiratory distress. Involuntary muscle spasms are not directly related to central venous catheter placement and are of lower priority compared to respiratory issues.

2. A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for the development of decubitus ulcers?

• A. A 79-year-old malnourished client on bed rest
• B. An obese client who uses a wheelchair
• C. A client who had 3 episodes of incontinent diarrhea
• D. An 80-year-old ambulatory diabetic client

Correct answer: A

Rationale: A malnourished client on bed rest is at the highest risk for developing decubitus ulcers due to a combination of factors such as poor nutritional status and immobility. Malnourished individuals have compromised skin integrity, making them more susceptible to pressure ulcers. Being on bed rest further exacerbates this risk as constant pressure on bony prominences can lead to tissue damage. Although the other choices may also be at risk for developing decubitus ulcers, the malnourished client on bed rest presents the highest risk due to the combination of malnutrition and immobility.

3. 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.

4. A client with a history of pancreatitis should avoid which of the following food choices?

• A. Noodles
• B. Vegetable soup
• C. Baked fish
• D. Cheddar cheese

Correct answer: D

Rationale: Clients with pancreatitis should avoid high-fat foods like cheddar cheese as they can exacerbate symptoms. Noodles, vegetable soup, and baked fish are generally lower in fat and may be better tolerated by clients with pancreatitis.

5. A client receiving filgrastim (Neupogen) for neutropenia is learning about compromised host precautions. The selection of which lunch suggests the client has learned about necessary dietary changes?

• A. grilled chicken sandwich and skim milk
• B. roast beef, mashed potatoes, and green beans
• C. peanut butter sandwich, banana, and iced tea
• D. barbecue beef, baked beans, and cole slaw

Correct answer: B

Rationale: Roast beef, mashed potatoes, and green beans are suitable choices for clients with neutropenia because they are considered safe options that help avoid potential sources of infection. Grilled chicken, peanut butter, and barbecue beef may carry a higher risk of bacterial contamination, which could be harmful to a client with compromised immunity.

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