Nursing Elites

1. Which dietary instruction is most important for a client with renal disease?

• A. Avoid all protein-rich foods.
• B. Limit fluid intake to 1500 ml/day.
• C. Increase potassium intake to prevent weakness.
• D. Eat small, frequent meals high in carbohydrates.

Correct answer: B

Rationale: The most important dietary instruction for a client with renal disease is to limit fluid intake to 1500 ml/day. This is essential to prevent fluid overload, manage electrolyte balance, and reduce strain on the kidneys. Choice A is incorrect because while protein restriction may be necessary in some cases, avoiding all protein-rich foods is not recommended as some protein intake is essential for overall health. Choice C is incorrect because increasing potassium intake is generally not advised for clients with renal disease, as they often need to limit potassium intake. Choice D is also incorrect because while consuming small, frequent meals may be helpful, emphasizing a diet high in carbohydrates is not typically the primary focus for clients with renal disease.

2. Which activity is most important for a client recovering from a hip replacement to avoid during the first few weeks of recovery?

• A. Sitting in a chair for short periods
• B. Crossing the legs while sitting
• C. Walking with assistance
• D. Performing light stretching exercises

Correct answer: B

Rationale: The correct answer is B: Crossing the legs while sitting. Cross-leg position after a hip replacement can significantly increase the risk of hip dislocation. During the first few weeks of recovery, it is crucial for clients to avoid crossing their legs to protect the new joint. Choices A, C, and D are not as critical during the initial recovery phase. Sitting in a chair for short periods, walking with assistance, and performing light stretching exercises are generally encouraged activities that can help in the recovery process without posing a significant risk of complications like hip dislocation.

3. A client with hypertension is prescribed lisinopril. What side effect should the nurse teach the client to monitor for?

• A. Monitor for a persistent cough.
• B. Monitor for bradycardia and dizziness.
• C. Report any signs of swelling or difficulty breathing.
• D. Monitor for headache and blurred vision.

Correct answer: A

Rationale: The correct answer is A: 'Monitor for a persistent cough.' Lisinopril, an ACE inhibitor, is associated with a common side effect of a persistent dry cough. This cough can be bothersome to the client and should be reported to their healthcare provider. Choices B, C, and D are incorrect because bradycardia, dizziness, swelling, difficulty breathing, headache, and blurred vision are not typically associated with lisinopril use.

4. A client with type 1 diabetes is found unconscious with a blood glucose of 40 mg/dL. What is the nurse's priority intervention?

• A. Administer a 50% dextrose bolus intravenously.
• B. Administer glucagon intramuscularly.
• C. Provide oral glucose gel.
• D. Recheck the blood glucose level in 15 minutes.

Correct answer: A

Rationale: The correct answer is to administer a 50% dextrose bolus intravenously. In unconscious clients with hypoglycemia, IV dextrose rapidly raises the blood glucose level. Glucagon would be a slower option and is typically used if IV access is unavailable. Oral glucose gel is not appropriate for an unconscious client as it requires swallowing and may cause aspiration. Rechecking the blood glucose level in 15 minutes delays immediate treatment and could lead to further deterioration.

5. A male client with heart failure presents with shortness of breath, audible wheezing, and pink frothy sputum. What action should the nurse take?

• A. Consult with the charge nurse regarding morphine prescription.
• B. Administer the dose of morphine sulfate as prescribed.
• C. Withhold morphine until dyspnea resolves.
• D. Review the need for the prescription with the healthcare provider.

Correct answer: B

Rationale: The correct answer is B: Administer the dose of morphine sulfate as prescribed. In heart failure, morphine helps reduce anxiety, preload, and afterload on the heart, improving oxygenation. The client's symptoms indicate acute decompensated heart failure, and morphine should be administered promptly to relieve distress. Consulting the charge nurse (Choice A) or withholding morphine (Choice C) would delay necessary treatment. Reviewing the prescription with the healthcare provider (Choice D) is not needed in this acute situation.

Similar Questions