Nursing Elites

1. A client reports constipation, and a nurse is providing dietary teaching. Which of the following foods should the nurse recommend?

• A. Macaroni and cheese
• B. One medium apple with skin
• C. One cup of plain yogurt
• D. Roast chicken and white rice

Correct answer: B

Rationale: The correct answer is B: One medium apple with skin. Foods high in fiber, like apples with skin, are recommended to relieve constipation due to their fiber content, which aids in bowel regularity. Macaroni and cheese, yogurt, and roast chicken with white rice do not provide as much fiber and are less effective in alleviating constipation. While yogurt can sometimes contain probiotics that support gut health, it is not as effective in treating constipation as high-fiber foods like apples.

2. A healthcare professional is reviewing a client's fluid and electrolyte status. Which of the following findings should the healthcare professional report to the provider?

• A. BUN 15 mg/dL
• B. Creatinine 0.8 mg/dL
• C. Sodium 143 mEq/L
• D. Potassium 5.4 mEq/L

Correct answer: D

Rationale: The correct answer is D. A potassium level of 5.4 mEq/L is above the expected reference range, indicating hyperkalemia. Hyperkalemia can lead to serious complications such as dysrhythmias, making it important for the healthcare professional to report this finding to the provider for further evaluation and intervention. Choices A, B, and C fall within normal ranges and do not pose an immediate risk to the client's health, so they would not warrant immediate reporting to the provider. Elevated BUN or creatinine levels may indicate kidney dysfunction, while a sodium level of 143 mEq/L falls within the normal range for adults and does not typically require urgent intervention.

3. During an abdominal assessment for an adult client, what is the correct sequence of steps?

• A. Inspect, Auscultate, Percuss, Palpate
• B. Palpate, Percuss, Inspect, Auscultate
• C. Auscultate, Inspect, Percuss, Palpate
• D. Percuss, Palpate, Inspect, Auscultate

Correct answer: A

Rationale: The correct sequence for an abdominal assessment in an adult client is to first Inspect the abdomen for any visible abnormalities, then Auscultate to listen for bowel sounds, followed by Percussion to assess for organ size and presence of fluid or masses, and finally Palpation to feel for tenderness, masses, or organ enlargement. Choice A, 'Inspect, Auscultate, Percuss, Palpate,' is the correct sequence for an abdominal assessment. Choices B, C, and D are incorrect because they do not follow the recommended sequence of assessment. Palpation should be the last step as it can potentially alter bowel sounds and percussion findings if done before. This deviation can lead to missing important findings or inaccurate assessment results.

4. The healthcare provider is monitoring a client in active labor. Which pattern on the fetal heart monitor requires immediate intervention?

• A. Early decelerations
• B. Late decelerations
• C. Accelerations
• D. Moderate variability

Correct answer: B

Rationale: Late decelerations are concerning as they indicate uteroplacental insufficiency, potentially resulting in fetal hypoxia. Immediate intervention is necessary to address the underlying cause and ensure fetal well-being. Early decelerations are typically benign and associated with head compression during contractions. Accelerations are reassuring and indicate fetal well-being. Moderate variability is a normal finding and indicates a healthy autonomic nervous system response. Therefore, late decelerations (Choice B) require immediate attention, while the other patterns are generally considered normal or benign during labor.

5. The healthcare professional is caring for a client with a chest tube. What is the most important action for the healthcare professional to take to ensure the chest tube is functioning properly?

• A. Milk the chest tube to ensure patency.
• B. Clamp the chest tube when moving the client.
• C. Ensure the water seal chamber is filled to the appropriate level.
• D. Secure the chest tube to the client's bed.

Correct answer: C

Rationale: Ensuring the water seal chamber is filled to the appropriate level is crucial to maintain the effectiveness of the chest tube drainage system. This step helps prevent air from entering the pleural space, ensuring proper lung re-expansion. 'Milking' the chest tube is not recommended as it can cause damage to the chest tube and surrounding tissues. Clamping the chest tube is not advisable as it can lead to tension pneumothorax. Securing the chest tube to the bed is important for stability but does not directly impact the functioning of the chest tube.

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