Nursing Elites

1. The nurse is conducting diet teaching for a client diagnosed with hypertension. Which foods should the nurse encourage the client to eat?

• A. Pickled olives
• B. Canned soup
• C. Fresh or frozen vegetables without sauce
• D. Fruits without sauce

Correct answer: C

Rationale: The correct answer is C: Fresh or frozen vegetables without sauce. These foods are low in sodium, which is crucial for managing hypertension. Pickled olives (choice A) and canned soup (choice B) are high in sodium, which can exacerbate hypertension. While fruits without sauce (choice D) are generally healthy, emphasizing vegetables is more beneficial for hypertension due to their lower sodium content.

2. The nurse is preparing a female client for discharge after being treated for a urinary tract infection (UTI). Which statement by the client indicates a need for further teaching?

• A. I will use douches regularly to prevent future infections.
• B. I should drink at least 8 glasses of water a day.
• C. I should avoid tight-fitting clothing.
• D. I will wipe from front to back after using the toilet.

Correct answer: A

Rationale: The correct answer is A. Using douches is not recommended as it can disrupt the natural flora and increase the risk of infections. Choices B, C, and D are all correct statements that can help prevent UTIs. Drinking an adequate amount of water helps flush out bacteria, avoiding tight-fitting clothing promotes ventilation and reduces moisture, and wiping from front to back prevents the spread of bacteria from the anal region to the urethra.

3. A client is admitted with an epidural hematoma after a skateboarding accident. How should the nurse differentiate the vascular source of intracranial bleeding?

• A. Monitor for clear fluid leakage from the nose.
• B. Assess for rapid onset of decreased level of consciousness.
• C. Check for bruising around the head and neck.
• D. Assess for changes in pupil size and reactivity.

Correct answer: B

Rationale: An epidural hematoma is characterized by a rapid onset of symptoms, including decreased level of consciousness, due to arterial bleeding, which differentiates it from other types of intracranial hemorrhage. Monitoring for clear fluid leakage from the nose (choice A) is more indicative of a basilar skull fracture and cerebrospinal fluid leak. Checking for bruising around the head and neck (choice C) is more suggestive of soft tissue injuries or facial fractures. Assessing for changes in pupil size and reactivity (choice D) is essential in evaluating traumatic brain injuries, but it is not specific to differentiating the vascular source of intracranial bleeding in an epidural hematoma.

4. A client with heart failure receiving furosemide develops muscle weakness. What is the nurse's priority action?

• A. Administer potassium supplements as prescribed.
• B. Monitor the client’s potassium levels.
• C. Instruct the client to increase their salt intake.
• D. Discontinue the furosemide.

Correct answer: B

Rationale: Muscle weakness in a client receiving furosemide (a diuretic) is often a sign of hypokalemia, as furosemide increases potassium loss. Monitoring potassium levels is essential to identify and address any imbalances and prevent complications such as arrhythmias. Administering potassium supplements without monitoring the levels can lead to hyperkalemia, which has its own set of serious complications. Instructing the client to increase salt intake is not appropriate in this situation as it does not address the underlying electrolyte imbalance. Discontinuing furosemide abruptly can worsen heart failure symptoms; therefore, monitoring potassium levels and adjusting the treatment accordingly is the most appropriate action.

5. A client with hypothyroidism is prescribed levothyroxine. What instruction should the nurse provide?

• A. Take the medication in the morning before eating.
• B. Take the medication with a full glass of water.
• C. Take the medication with food to avoid nausea.
• D. Take the medication only when symptoms worsen.

Correct answer: A

Rationale: The correct answer is A: 'Take the medication in the morning before eating.' Levothyroxine should be taken on an empty stomach in the morning for optimal absorption. Choice B is incorrect because while taking medication with water is generally recommended, levothyroxine specifically needs to be taken on an empty stomach. Choice C is incorrect as taking levothyroxine with food can interfere with its absorption. Choice D is incorrect as levothyroxine should be taken regularly as prescribed, not only when symptoms worsen.

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