Nursing Elites

1. A client with lactose intolerance needs to increase calcium intake. Which food should the nurse recommend?

• A. Spinach
• B. Peanut butter
• C. Ground beef
• D. Carrots

Correct answer: A

Rationale: Spinach is a suitable choice to recommend for increasing calcium intake to a client with lactose intolerance. Spinach is a good non-dairy source of calcium. Peanut butter, ground beef, and carrots are not significant sources of calcium. Peanut butter is high in protein and fats, ground beef is a source of protein and iron, and carrots are rich in vitamin A and fiber, but none of these choices provide a substantial amount of calcium.

2. A nurse is caring for a client with a new prescription for clindamycin. Which of the following should the nurse monitor?

• A. Liver function
• B. Serum potassium
• C. Signs of superinfection
• D. Blood glucose

Correct answer: C

Rationale: The correct answer is C: Signs of superinfection. Clindamycin can lead to antibiotic-associated colitis and other superinfections, making it crucial for the nurse to monitor the client for signs of superinfection. Monitoring liver function (choice A) is not typically associated with clindamycin use. Serum potassium levels (choice B) and blood glucose (choice D) are also not directly affected by clindamycin, so they are not the priority for monitoring in this case.

3. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?

• A. Administer oxytocin to the client via intravenous infusion
• B. Apply oxygen at 2 L/min via nasal cannula
• C. Prepare for insertion of an intrauterine pressure catheter
• D. Assist the client into the knee-chest position

Correct answer: D

Rationale: The nurse should assist the client into the knee-chest position to relieve pressure on the umbilical cord. This position helps to prevent cord compression and improves fetal oxygenation. Administering oxytocin (Choice A) could worsen the situation by increasing contractions and potentially compressing the umbilical cord. Applying oxygen (Choice B) is not the priority in this emergency situation. Preparing for insertion of an intrauterine pressure catheter (Choice C) is not appropriate as the immediate concern is relieving pressure on the umbilical cord.

4. A nurse is caring for a client with Alzheimer's disease. Which action should the nurse include in the care plan to support the client’s cognitive function?

• A. Place a daily calendar in the kitchen
• B. Replace buttoned clothing with zippered items
• C. Replace carpet with hardwood floors
• D. Create variation in the daily routine

Correct answer: A

Rationale: Placing a daily calendar in the kitchen is beneficial for clients with Alzheimer's disease as it helps in orienting them to time and enhances cognitive function. This visual aid can assist in keeping track of days and activities. Choice B, replacing buttoned clothing with zippered items, is more related to promoting independence in dressing rather than directly supporting cognitive function. Choice C, replacing carpet with hardwood floors, focuses on safety and mobility rather than cognitive function. Choice D, creating variation in the daily routine, may be helpful for engagement and stimulation but does not directly address cognitive function as effectively as using a daily calendar.

5. What is the nurse's next action after a laboring client's membranes have just ruptured?

• A. Assess fetal heart rate pattern
• B. Monitor uterine contractions
• C. Administer oxygen
• D. Prepare for delivery

Correct answer: A

Rationale: After a laboring client's membranes have ruptured, the nurse's immediate priority is to assess the fetal heart rate pattern. This assessment is crucial to ensure the fetus is not in distress, especially to rule out umbilical cord compression that could affect blood flow to the fetus. While monitoring uterine contractions is important, assessing the fetal heart rate takes precedence in this situation as it directly reflects the fetus's well-being. Administering oxygen may be necessary later depending on the fetal status, and preparing for delivery should only occur if the assessment indicates fetal distress or other complications. Therefore, the correct next action for the nurse is to assess the fetal heart rate pattern.

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