Nursing Elites

1. A nurse is caring for a client who has a new diagnosis of hypercholesterolemia. Which of the following dietary recommendations should the nurse make?

• A. Increase intake of red meat
• B. Consume foods high in saturated fats
• C. Choose foods low in trans fats
• D. Limit intake of vegetables and fruits

Correct answer: C

Rationale: The correct answer is C: 'Choose foods low in trans fats.' Trans fats are known to increase cholesterol levels, so avoiding foods high in trans fats is essential in managing hypercholesterolemia. Option A, increasing intake of red meat, and option B, consuming foods high in saturated fats, can worsen cholesterol levels as they are sources of unhealthy fats. Option D, limiting intake of vegetables and fruits, is incorrect as they are part of a heart-healthy diet and should be encouraged for individuals with hypercholesterolemia.

2. A patient refused a newly open fentanyl patch. Which of the following actions should the nurse take?

• A. Ask another nurse to witness the disposal of the new patch
• B. Dispose of the patch in a sharps container
• C. Send the patch back to the pharmacy
• D. Document the refusal and remove the patch

Correct answer: A

Rationale: The correct action for the nurse to take when a patient refuses a newly open fentanyl patch is to ask another nurse to witness the disposal of the new patch. This is essential for accountability and ensuring proper disposal procedures are followed. Choice B is incorrect because disposing of the patch in a sharps container without a witness does not ensure proper accountability. Choice C is incorrect as sending the patch back to the pharmacy is not the appropriate action for disposal. Choice D is incorrect because although documenting the refusal is important, it is also crucial to ensure proper disposal of the unused patch by having another nurse witness it.

3. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care?

• A. Use sterile technique when performing tracheostomy care.
• B. Replace the tracheostomy ties every 24 hours.
• C. Use a sterile brush to clean the inner cannula.
• D. Change the tracheostomy dressing once a week.

Correct answer: C

Rationale: The correct answer is to use a sterile brush to clean the inner cannula. This action is crucial to prevent infection during tracheostomy care. Choice A is incorrect as clean technique is not adequate for tracheostomy care, sterile technique is required. Choice B is incorrect as tracheostomy ties should be replaced when soiled, not routinely every 24 hours. Choice D is incorrect as tracheostomy dressings should be changed more frequently to maintain cleanliness and prevent infection.

4. How should signs of infection in a post-surgical patient be assessed?

• A. Check the surgical site
• B. Check the patient's vital signs
• C. Monitor for fever
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: Assessing the surgical site is crucial in identifying early signs of infection post-surgery. Changes such as redness, swelling, warmth, or drainage may indicate an infection developing. While monitoring vital signs and fever are important in infection assessment, they are general indicators and may not show localized signs at the surgical site. Checking for abnormal breath sounds is more relevant when assessing respiratory issues rather than infection at the surgical site.

5. A nurse is assessing a newborn immediately following birth. Which of the following findings should the nurse report to the provider?

• A. Acrocyanosis
• B. Vernix caseosa
• C. A respiratory rate of 50/min
• D. Heart rate of 160/min

Correct answer: D

Rationale: The correct answer is D, a heart rate of 160/min. A heart rate of 160/min in a newborn exceeds the normal range and could indicate potential issues that need further evaluation by the provider. Acrocyanosis (choice A) is a common finding in newborns and is not concerning. Vernix caseosa (choice B) is a white, cheesy substance found on newborn skin and is a normal finding. While a respiratory rate of 50/min (choice C) is slightly elevated, it is not as concerning as a high heart rate in a newborn.

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