Nursing Elites

1. What are the risk factors for developing hypertension?

• A. High sodium diet and lack of physical activity
• B. Low potassium intake and excessive alcohol consumption
• C. Frequent exercise and low cholesterol diet
• D. Smoking and family history

Correct answer: A

Rationale: The correct answer is A: High sodium diet and lack of physical activity. These are established risk factors for developing hypertension as they contribute to elevated blood pressure. Choice B, low potassium intake and excessive alcohol consumption, may also impact blood pressure but are not as strongly associated with hypertension as high sodium intake and lack of physical activity. Choice C, frequent exercise and a low cholesterol diet, are actually beneficial for reducing the risk of hypertension. Choice D, smoking and family history, are more closely linked to other health conditions such as cardiovascular diseases, rather than being primary risk factors for hypertension.

2. A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for the client?

• A. White flour tortillas.
• B. Potato pancakes.
• C. Wheat crackers.
• D. Canned barley soup.

Correct answer: B

Rationale: The correct answer is B, potato pancakes. Individuals with celiac disease must avoid gluten-containing foods. Potato pancakes are gluten-free, making them a suitable choice for someone with celiac disease. Choice A, white flour tortillas, contains gluten from wheat flour, making it unsuitable for a client with celiac disease. Choice C, wheat crackers, also contain gluten and should be avoided. Choice D, canned barley soup, contains barley which is a gluten-containing grain and is not appropriate for someone with celiac disease.

3. A nurse is contributing to the plan of care for a client following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include?

• A. Administer antibiotics
• B. Irrigate the bladder using sterile technique
• C. Avoid irrigating the bladder
• D. Insert a urinary catheter

Correct answer: B

Rationale: Irrigating the bladder using sterile technique is crucial in the care of a client following a transurethral resection of the prostate (TURP). This intervention helps prevent infection and maintains patency of the urinary catheter, promoting healing. Administering antibiotics (Choice A) may be necessary if there is an infection present, but it is not a routine intervention following TURP. Avoiding bladder irrigation (Choice C) is not recommended as it can lead to clot retention and other complications. Inserting a urinary catheter (Choice D) is usually already done during the TURP procedure and is not a postoperative intervention.

4. A client is learning to use a cane due to left-leg weakness. Which instruction is correct?

• A. Use the cane on the stronger side of the body
• B. Maintain two points of support on the floor at all times
• C. Advance the cane and the strong leg together
• D. Advance the cane 30 to 45 cm with each step

Correct answer: B

Rationale: The correct instruction when using a cane due to leg weakness is to maintain two points of support on the floor at all times. This provides stability and support while walking. Choice A is incorrect because the cane should be used on the weaker side to provide assistance. Choice C is incorrect as the cane and weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.

5. A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be

• A. Confused with cold, clammy skin and a pulse of 110
• B. Lethargic with hot, dry skin and rapid, deep respirations
• C. Alert and cooperative with a BP of 130/80 and respirations of 12
• D. Short of breath, with distended neck veins and a bounding pulse of 96

Correct answer: A

Rationale: The correct answer is A. Low blood sugar levels (50 mg/dL) typically cause confusion, cold clammy skin, and an increased pulse (tachycardia). Option A correctly describes the expected symptoms of hypoglycemia, which include confusion due to the brain's inadequate glucose supply, cold and clammy skin due to sympathetic nervous system activation, and an increased pulse (110 bpm) as the body reacts to low blood sugar levels. Options B, C, and D describe symptoms that are not typically associated with hypoglycemia. Lethargy, hot dry skin, rapid deep respirations, normal vital signs, shortness of breath, distended neck veins, and bounding pulse are more indicative of other conditions or normal physiological responses, not hypoglycemia.

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