Nursing Elites

1. A nurse is reviewing the medical record of a client who has major depressive disorder and is taking tranylcypromine. Which of the following foods should the nurse instruct the client to avoid?

• A. Milk
• B. Bananas
• C. Yogurt
• D. Cured meats

Correct answer: D

Rationale: The correct answer is D: Cured meats. Cured meats contain tyramine, which can lead to a hypertensive crisis in clients taking tranylcypromine. Bananas, milk, and yogurt do not contain significant amounts of tyramine and are safe for clients taking this medication. Therefore, the nurse should instruct the client to avoid cured meats to prevent adverse effects.

2. A nurse is caring for a client who is 2 hours postoperative following a thoracotomy. Which of the following findings should the nurse report to the provider?

• A. Chest tube drainage of 60 mL/hr
• B. Oxygen saturation of 95%
• C. Chest tube drainage of 120 mL/hr
• D. Heart rate of 88/min

Correct answer: C

Rationale: The correct answer is C. Chest tube drainage of more than 100 mL/hr may indicate active bleeding, which is a serious complication post-thoracotomy surgery. This finding should be reported to the healthcare provider immediately for further evaluation and intervention. Choices A, B, and D are within normal limits for a client 2 hours post-thoracotomy and do not require immediate reporting. Oxygen saturation of 95% is acceptable, and a heart rate of 88/min is within the normal range for an adult.

3. A client has a nasogastric tube and is receiving intermittent enteral feedings. Which of the following actions should the nurse take to prevent aspiration?

• A. Administer a bolus feeding over 10 minutes.
• B. Elevate the head of the bed to 45 degrees during feedings.
• C. Flush the tube with 10 mL of sterile water before feedings.
• D. Position the client on the left side during feedings.

Correct answer: B

Rationale: To prevent aspiration in clients with a nasogastric tube receiving intermittent enteral feedings, the nurse should elevate the head of the bed to 45 degrees during feedings. This position helps reduce the risk of regurgitation and aspiration of the feeding contents. Administering a bolus feeding over 10 minutes (choice A) may not prevent aspiration as effectively as elevating the head of the bed. Flushing the tube with sterile water before feedings (choice C) is important for tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (choice D) is not the recommended action to prevent aspiration; elevating the head of the bed is more effective.

4. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

• A. Stay in bed for at least 1 hour if unable to fall asleep.
• B. Take a 1-hour nap during the day.
• C. Perform exercise before bed.
• D. Eat a light snack before bedtime.

Correct answer: D

Rationale: The correct answer is to eat a light snack before bedtime. Consuming a light snack can help promote sleep by preventing discomfort from hunger. Choice A is incorrect because staying in bed for too long when unable to fall asleep can lead to frustration and worsen insomnia. Choice B is incorrect as taking a nap during the day can interfere with nighttime sleep. Choice C is incorrect as exercising before bed can increase alertness and make falling asleep more difficult.

5. A nurse is preparing to administer packed RBCs to a client. Which of the following actions should the nurse take first?

• A. Prime the IV tubing with dextrose 5% in water
• B. Ensure the client's consent is on file
• C. Check the client's identification using two identifiers
• D. Administer the blood through a 22-gauge catheter

Correct answer: C

Rationale: The correct first action for the nurse to take when preparing to administer packed RBCs is to check the client's identification using two identifiers. This step is crucial to ensure that the right blood is given to the right client, preventing any transfusion errors. Priming the IV tubing with dextrose 5% in water and administering the blood through a 22-gauge catheter are important steps but should come after confirming the client's identity. Ensuring the client's consent is on file is also important but is not the immediate priority when preparing to administer packed RBCs.

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