Nursing Elites

1. A client with hypertension is being taught about dietary modifications by a nurse. Which of the following food choices should the nurse recommend?

• A. Canned tomato soup
• B. Baked chicken breast
• C. Processed cheese
• D. Pickled vegetables

Correct answer: B

Rationale: The correct answer is Baked chicken breast. It is low in sodium and a healthy option for clients with hypertension. Canned tomato soup and processed cheese are typically high in sodium, which is not recommended for individuals with hypertension. Pickled vegetables are also high in sodium and should be avoided in a hypertension-friendly diet.

2. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?

• A. Decreased deep tendon reflexes
• B. Positive Trousseau’s sign
• C. Hypoactive bowel sounds
• D. Sticky mucous membranes

Correct answer: A

Rationale: A sodium level of 122 mEq/L indicates hyponatremia, which is characterized by decreased deep tendon reflexes. Hyponatremia leads to neurological symptoms such as altered reflexes. Choices B, C, and D are not typically associated with hyponatremia. Positive Trousseau’s sign is related to hypocalcemia, hypoactive bowel sounds can be seen in paralytic ileus or decreased peristalsis, and sticky mucous membranes are not specific findings related to sodium imbalances.

3. A nurse is caring for a toddler diagnosed with respiratory syncytial virus (RSV). Which of the following actions should the nurse take?

• A. Use a designated stethoscope when caring for the toddler
• B. Wear an N95 respirator mask
• C. Remove the disposable gown after leaving the toddler’s room
• D. Place the toddler in a room with negative air pressure

Correct answer: A

Rationale: Using a designated stethoscope is the correct action when caring for a toddler diagnosed with RSV. This measure helps prevent the spread of infection to other clients by reducing the risk of contamination. Wearing an N95 respirator mask is not necessary for routine care of a toddler with RSV unless performing aerosol-generating procedures. Removing the disposable gown after leaving the toddler's room is important for infection control but not specific to RSV care. Placing the toddler in a room with negative air pressure is not a standard practice for managing RSV in toddlers.

4. A nurse is admitting a client who is in labor and at 38 weeks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2 (HSV-2). Which of the following questions is most appropriate for the nurse to ask the client?

• A. Have your membranes ruptured?
• B. How far apart are your contractions?
• C. Do you have any active lesions?
• D. Are you positive for beta strep?

Correct answer: C

Rationale: The most appropriate question for the nurse to ask the client in this scenario is whether they have any active lesions. Active lesions from HSV-2 during labor increase the risk of neonatal transmission, which would necessitate a cesarean section to prevent the infant from contracting the virus during delivery. Asking about the presence of active lesions is crucial to determine the appropriate management and precautions needed to protect the newborn. Choices A, B, and D are not as pertinent in this situation and do not directly address the potential risk of neonatal transmission of HSV-2.

5. A nurse is caring for a client with a history of heroin use who is intoxicated. Which finding should the nurse expect?

• A. Constricted pupils
• B. Dilated pupils
• C. Increased reflexes
• D. Elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Constricted pupils. Constricted pupils are a classic sign of opioid intoxication, including heroin. Opioids like heroin cause the pupils to constrict due to their effect on the autonomic nervous system. Dilated pupils, increased reflexes, and elevated blood pressure are not typically associated with opioid intoxication but may be seen with other substances or conditions.

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