Nursing Elites

1. A nurse is reinforcing teaching to a group of older adults about sources of complete and incomplete protein. Which of the following foods should the nurse include as a complete protein?

• A. Yogurt
• B. Fresh vegetables
• C. Nuts
• D. Dried beans

Correct answer: A

Rationale: Corrected Rationale: Yogurt contains all essential amino acids, making it a complete protein. Choice B, fresh vegetables, are incomplete proteins. Choice C, nuts, are also incomplete proteins. Choice D, dried beans, are incomplete proteins. Therefore, the correct answer is yogurt because it is a source of complete protein.

2. During an assessment on a client in congestive heart failure, what is most likely to be revealed upon auscultation of the heart?

• A. S3 ventricular gallop
• B. Apical click
• C. Systolic murmur
• D. Split S2

Correct answer: A

Rationale: The correct answer is A: S3 ventricular gallop. An S3 sound is a common finding in congestive heart failure due to fluid overload in the heart. It is associated with decreased ventricular compliance. Choices B, C, and D are incorrect. An apical click is not typically associated with congestive heart failure. A systolic murmur may be heard in conditions like mitral regurgitation but is not specific to congestive heart failure. A split S2 is associated with conditions like pulmonary hypertension, not congestive heart failure.

3. A nurse is reinforcing teaching about foods that enhance iron absorption when consumed with nonheme iron with a client who has iron deficiency anemia. Which of the following foods should the nurse include in the teaching?

• A. Tomato juice
• B. Tea
• C. Milk
• D. Dried beans

Correct answer: A

Rationale: The correct answer is A, Tomato juice. Tomato juice is high in vitamin C, which enhances the absorption of nonheme iron from foods. Vitamin C helps convert nonheme iron to a form that is easier for the body to absorb. Tea (choice B) contains tannins that can inhibit iron absorption. Milk (choice C) contains calcium, which can interfere with iron absorption. Dried beans (choice D) are a good source of nonheme iron but do not enhance iron absorption when consumed with nonheme iron.

4. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?

• A. Bruising at the operative site
• B. Elevated heart rate
• C. Decreased platelet count
• D. No bowel movement for 3 days

Correct answer: D

Rationale: The correct answer is D. Constipation is a common side effect of Tylenol #3, which contains codeine. Codeine can slow down bowel movements, leading to constipation. Monitoring for constipation and implementing management strategies is crucial. Choices A, B, and C are incorrect because bruising at the operative site, elevated heart rate, and decreased platelet count are not commonly associated side effects of Tylenol #3.

5. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?

• A. Blood urea nitrogen 50 mg/dl
• B. Hemoglobin of 10.3 g/dl
• C. Venous blood pH 7.30
• D. Serum potassium 6 mEq/L

Correct answer: D

Rationale: A serum potassium level of 6 mEq/L indicates hyperkalemia, which can be life-threatening and requires immediate intervention. Hyperkalemia can lead to dangerous cardiac arrhythmias and must be addressed promptly. The other options are not as urgent. A blood urea nitrogen level of 50 mg/dl may indicate kidney dysfunction but does not require immediate intervention. Hemoglobin of 10.3 g/dl may suggest anemia, which needs management but is not an immediate threat. A venous blood pH of 7.30 may indicate acidosis, which is concerning but not as acutely dangerous as hyperkalemia.

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