Nursing Elites

1. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. Which food should the nurse instruct the client to avoid?

• A. Steamed carrots
• B. Orange slices
• C. Mashed potatoes
• D. Baked chicken

Correct answer: B

Rationale: Correct! Orange slices should be avoided by clients on a mechanical soft diet as they can be difficult to chew and swallow. Steamed carrots, mashed potatoes, and baked chicken are suitable choices for a mechanical soft diet, as they are softer in texture and easier to consume without posing a risk of choking or swallowing difficulties.

2. When reviewing the health history of an older adult with a hip fracture, what should a nurse identify as a risk factor for developing pressure injuries?

• A. Malnutrition
• B. Poor hygiene
• C. Urinary incontinence
• D. Immobility

Correct answer: C

Rationale: Urinary incontinence is a risk factor for skin breakdown, which can lead to the development of pressure injuries. While malnutrition, poor hygiene, and immobility are important considerations in overall patient care, they are not specifically identified as significant risk factors for pressure injuries in this scenario.

3. A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. What action should the nurse take?

• A. Dissolve crushed tablet medications in tap water
• B. Administer all medications together
• C. Flush the NG tube with 60 mL of water before each medication
• D. Dissolve medications separately and flush with sterile water

Correct answer: D

Rationale: The correct action for the nurse to take when administering medications through a nasogastric (NG) tube is to dissolve medications separately and flush the tube with sterile water. This is important to prevent interactions between medications and ensure accurate administration. Option A is incorrect because tap water may not be sterile and could lead to contamination. Option B is incorrect as it increases the risk of drug interactions and may affect the effectiveness of each medication. Option C is incorrect as 60 mL of water before each medication may not be enough to ensure proper medication delivery and prevent interactions.

4. A nurse in an emergency department is monitoring the hydration status of a client receiving oral rehydration. What finding should the nurse intervene for?

• A. Heart rate of 80 beats per minute
• B. Heart rate of 120 beats per minute
• C. Blood pressure of 110/70 mmHg
• D. Respiratory rate of 16 breaths per minute

Correct answer: B

Rationale: A heart rate of 120 beats per minute indicates tachycardia, which can be a sign of dehydration and requires intervention. A heart rate of 80 beats per minute is within the normal range and does not indicate dehydration. A blood pressure of 110/70 mmHg is considered normal. A respiratory rate of 16 breaths per minute is also within the normal range and does not point towards dehydration.

5. A nurse is caring for a client who is experiencing fluid volume deficit (FVD). What clinical finding should the nurse expect?

• A. Decreased hematocrit
• B. Increased heart rate
• C. Increased blood pressure
• D. Decreased respiratory rate

Correct answer: B

Rationale: Increased heart rate is a common sign of fluid volume deficit (FVD) as the body compensates for decreased fluid levels. When a client is experiencing FVD, the body tries to maintain perfusion to vital organs by increasing the heart rate. This compensatory mechanism helps to improve cardiac output and maintain blood pressure. Choices A, C, and D are incorrect because in FVD, hematocrit may be increased due to hemoconcentration, blood pressure tends to decrease as a compensatory response to FVD, and respiratory rate is usually unaffected or may increase due to attempts to maintain oxygenation.

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