Nursing Elites

1. The client with a new diagnosis of type 2 diabetes is being taught about diet management by the nurse. Which statement by the client indicates effective learning?

• A. I should not avoid all carbohydrates
• B. I can eat whatever I want as long as I take my medication
• C. I need to eat regular meals and snacks to maintain my blood sugar levels
• D. I will decrease my intake of sugary foods to prevent low blood sugar

Correct answer: C

Rationale: Choice C is the correct answer because eating regular meals and snacks is crucial for maintaining stable blood sugar levels in individuals with diabetes. This approach helps prevent spikes and drops in blood sugar, promoting better management of the condition. Choices A, B, and D are incorrect. Avoiding all carbohydrates is not recommended as they are a major energy source and can be part of a balanced diet; eating whatever one wants while relying solely on medication can lead to uncontrolled blood sugar levels and complications; decreasing sugary foods intake can actually contribute to high blood sugar levels rather than preventing low blood sugar.

2. Which client assessment falls within the scope of practice for the practical nurse?

• A. An agitated client with bilateral wrist restraints
• B. New admission of a client with deep vein thrombosis
• C. Return of a post-anesthesia client following a colon resection
• D. Transfer of a client with sepsis from a long-term care facility

Correct answer: B

Rationale: The correct answer is B because assessing a new deep vein thrombosis (DVT) patient is within the scope of practical nursing. It involves monitoring and supporting the circulatory system health, which is a common responsibility for practical nurses. Choices A, C, and D involve scenarios that are typically beyond the initial assessment and care provided by practical nurses. An agitated client with bilateral wrist restraints may require immediate intervention by higher-level healthcare providers due to safety concerns and potential underlying issues. The return of a post-anesthesia client following a colon resection and the transfer of a client with sepsis involve more specialized care that goes beyond the typical responsibilities of a practical nurse, often requiring interventions from registered nurses or physicians.

3. The client with heart failure is prescribed furosemide (Lasix). What should the nurse include in the teaching plan?

• A. Increase potassium-rich foods in the diet
• B. Avoid foods high in sodium
• C. Monitor fluid intake and adjust as needed
• D. Take the medication in the morning

Correct answer: A

Rationale: The correct answer is to instruct the client to increase potassium-rich foods in the diet. Furosemide is a loop diuretic that can cause potassium loss as a side effect. By increasing potassium-rich foods, the client can help prevent hypokalemia, a potential complication of furosemide therapy. Choice B is incorrect because while limiting sodium intake is generally advisable for heart failure, it is not directly related to furosemide use. Choice C is incorrect because fluid intake should be monitored and adjusted based on the individual's condition, but setting a specific limit of 1 liter per day is not a standard recommendation. Choice D is incorrect because furosemide is usually taken in the morning to prevent disturbances in sleep due to increased urination during the night.

4. A client with a history of hypertension is admitted to the hospital for a suspected myocardial infarction. Which of the following is the priority nursing action?

• A. Administer oxygen as prescribed
• B. Perform an ECG
• C. Obtain a detailed health history
• D. Monitor vital signs regularly

Correct answer: B

Rationale: The priority nursing action in this scenario is to perform an ECG. An ECG is crucial in confirming myocardial infarction promptly and guiding immediate treatment decisions. Administering oxygen as prescribed is important but not the priority over confirming the diagnosis. Obtaining a detailed health history is relevant but does not take precedence over immediate diagnostic confirmation. While monitoring vital signs regularly is essential, performing an ECG is the priority action in this scenario to guide timely management.

5. The nurse notes that a postoperative client's wound site is red and slightly swollen. What is the most appropriate action?

• A. Apply an ice pack
• B. Document the findings and monitor
• C. Notify the surgeon
• D. Clean the wound with sterile saline

Correct answer: C

Rationale: The correct answer is to notify the surgeon. Redness and swelling at a wound site can indicate an infection, which may require medical intervention. Applying an ice pack (choice A) is not appropriate without further assessment. While documenting the findings and monitoring (choice B) is important, it should be accompanied by notifying the surgeon for further evaluation. Cleaning the wound with sterile saline (choice D) may not be sufficient if an infection is present, so immediate communication with the surgeon is crucial.

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