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The physician has ordered a low-potassium diet for a client with renal failure. Which food should be limited due to its potassium content?
- A. Broccoli
- B. Bananas
- C. Lean beef
- D. White rice
Correct Answer: B
Rationale: Bananas, with ~400-450 mg potassium per fruit, must be limited on a low-potassium diet in renal failure, as impaired kidneys can't excrete excess, risking hyperkalemia broccoli's moderate, beef and rice's low potassium fit better. Nurses teach this, preventing cardiac issues, tailoring diets for renal safety.
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When a client wishes to improve the appearance of their eyes by removing excess skin from the face and neck, the nurse should provide teaching regarding which of the following procedures?
- A. Dermabrasion
- B. Rhinoplasty
- C. Blepharoplasty
- D. Rhytidectomy
Correct Answer: D
Rationale: Rhytidectomy (facelift) removes excess skin from face and neck.
The nurse questions a doctors order of Morphine sulfate 50 mg, IM for a client with pancreatitis. Which role best fit that statement?
- A. Change agent
- B. Client advocate
- C. Case manager
- D. Collaborator
Correct Answer: B
Rationale: Questioning a morphine order for pancreatitis exemplifies the client advocate role, where nurses safeguard patient well-being. Morphine can worsen pancreatitis by causing sphincter of Oddi spasm, unlike safer options like meperidine. By challenging this, the nurse protects the client from harm, a duty rooted in ethical codes like the ANA's. Change agents modify behaviors, case managers coordinate, and collaborators work jointly, but advocacy uniquely prioritizes patient safety over compliance. In practice, this might involve consulting the doctor for an alternative, ensuring care aligns with the patient's best interest, a critical nursing responsibility.
The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
- A. Tachypnea
- B. Eupnea
- C. Orthopnea
- D. Hyperventilation
Correct Answer: C
Rationale: Orthopnea is difficulty breathing relieved by an upright position.
The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?
- A. 6
- B. 9
- C. 12
- D. 15
Correct Answer: A
Rationale: A Glasgow Coma Scale (GCS) score of 6 (A) indicates coma, defined as ≤8, reflecting minimal responsiveness (eye, verbal, motor). Scores of 9 (B) and 12 (C) suggest moderate injury. 15 (D) is normal. A is correct. Rationale: GCS ≤8 signifies severe brain dysfunction, often requiring intubation, a standard threshold in neurocritical care for coma classification and management.
The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response?
- A. Call a code.
- B. Administer a bronchodilator.
- C. Contact the health care provider.
- D. Disconnect the suction source from the catheter.
Correct Answer: D
Rationale: A stuck catheter with coughing and wheezing suggests obstruction or bronchospasm; disconnecting the suction source (D) is the priority to relieve pressure and attempt removal. Calling a code (A) or provider (C) delays action. Bronchodilators (B) treat wheezing but not the immediate issue. D is correct. Rationale: Disconnecting stops suction trauma, allowing catheter withdrawal and airway reassessment, a critical first step per emergency airway protocols.