Nursing Elites

1. Which of the following foods present a problem for a client diagnosed with Celiac Disease?

• A. butter
• B. oats or barley cereal
• C. fresh vegetables
• D. coffee or tea

Correct answer: B

Rationale: Celiac disease, also known as celiac sprue, is a malabsorption disorder affecting the small intestine due to a problem with ingesting gluten, a protein found in wheat, rye, oats, and barley. Therefore, oats or barley cereal would present a problem for a client with Celiac Disease as they contain gluten. Fresh vegetables, butter, coffee, and tea, on the other hand, do not contain gluten and should not pose any issues for individuals with this disorder. Therefore, the correct answer is oats or barley cereal. Choices A, C, and D are not problematic for clients with Celiac Disease as they are gluten-free.

2. In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess?

• A. ability to speak
• B. ability to hear
• C. oxygen saturation
• D. adventitious breath sounds

Correct answer: A

Rationale: In an emergency situation to assess for airway obstruction, the nurse should prioritize assessing the client's ability to speak. If a client can speak, it indicates that the airway is patent and not completely obstructed, allowing air to pass through the vocal cords for speech production. Choices B, C, and D are not the primary assessments for determining airway obstruction. Assessing the ability to hear is not directly related to an airway obstruction. While oxygen saturation and adventitious breath sounds are important in respiratory assessments, they are not the initial indicators of an airway obstruction. Oxygen saturation reflects the amount of oxygen in the blood, and adventitious breath sounds refer to abnormal lung sounds that may indicate conditions like pneumonia or bronchitis, but they do not specifically confirm airway patency.

3. In a disaster triage situation, which of the following should the nurse be least concerned with regarding a client in crisis?

• A. ability to breathe
• B. pallor or cyanosis of the skin
• C. number of accompanying family members
• D. motor function

Correct answer: C

Rationale: During a disaster triage situation where quick decisions are crucial, the nurse's primary focus should be on factors directly related to the patient's immediate condition and survival. The ability to breathe, pallor or cyanosis of the skin, and motor function are critical indicators of a patient's health status and need for urgent intervention. In contrast, the number of accompanying family members, although important for emotional support, is not a priority when assessing and prioritizing care during a crisis. While emotional support is valuable, the focus in triage is on identifying and addressing the most critical and life-threatening issues first to maximize survival chances. Therefore, the nurse should be least concerned with the number of accompanying family members as it does not directly impact the patient's immediate medical needs in a crisis situation. Choices A, B, and D are all crucial factors to assess a client's health status and determine the urgency of intervention during a disaster triage. The ability to breathe indicates respiratory function, pallor or cyanosis of the skin reflect circulatory and oxygenation status, and motor function can hint at neurological impairment or injury, all of which are vital in determining the severity of the crisis and the immediate medical needs of the patient.

4. Which of the following is an appropriate nursing goal for a client at risk for nutritional problems?

• A. provide oxygen
• B. promote healthy nutritional practices
• C. treat complications of malnutrition
• D. increase weight

Correct answer: B

Rationale: The correct answer is to promote healthy nutritional practices. This goal focuses on preventive measures to address the client's nutritional risk. Providing oxygen (Choice A) is not directly related to addressing nutritional problems. Treating complications of malnutrition (Choice C) involves addressing the consequences rather than preventing or managing the nutritional problems. Increasing weight (Choice D) would only be appropriate if the client is underweight; it does not address the broader aspect of promoting overall healthy nutritional practices.

5. A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first?

• A. Report the nurse who changed the IV solution
• B. Document the error in the client's chart
• C. Call the client's health care provider
• D. Ask the nurse whether she intends to report the error

Correct answer: D

Rationale: The first thing the nurse who observed the error should do is ask the nurse whether she intends to report the error. Ensuring client safety is paramount, and all errors must be reported to the health care provider, but this is not the initial action. The client should also be assessed immediately. The nurse who discovered the error should complete an incident report and make appropriate documentation in the client's record. If the nurse who observed the error finds out that it will not be reported, it may be necessary to involve the supervisor. Therefore, the best course of action initially is to communicate with the nurse who made the error to understand her intentions regarding reporting.

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