Nursing Elites

1. A nurse is teaching a client who is lactose intolerant about dietary choices. Which food should the nurse recommend to increase calcium intake?

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

Correct answer: A

Rationale: The correct answer is A: Spinach. Spinach is rich in calcium, making it a suitable choice for individuals with lactose intolerance who need to avoid dairy products. Peanut butter, ground beef, and carrots are not significant sources of calcium compared to spinach, and therefore, not the best recommendation for increasing calcium intake in lactose-intolerant individuals.

2. A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?

• A. Fetal heart rate
• B. Client's blood pressure
• C. Client's respiratory rate
• D. Client's pain level

Correct answer: B

Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being. Fetal heart rate is important but monitoring the client's blood pressure takes precedence due to the risk of hypotension. Respiratory rate and pain level monitoring are also important but not the priority in this scenario.

3. A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hours. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times?

• A. 2100
• B. 900
• C. 1300
• D. 1800

Correct answer: D

Rationale: The trough level of vancomycin should be drawn just before the next dose is administered, typically about 30 minutes before the scheduled dose. Since the morning dose is at 0700, the trough level should be drawn at 1800. This timing ensures an accurate measurement of the lowest concentration of the drug in the client's system before the next dose is given. Choice A (2100) is too close to the next dose, choice B (900) is too early, and choice C (1300) is also too far from the next dose.

4. A client just received their first dose of lisinopril. Which of the following is an appropriate nursing intervention?

• A. Place the client on cardiac monitoring
• B. Monitor the client’s oxygen saturation
• C. Provide standby assistance when the client gets out of bed
• D. Encourage foods high in potassium

Correct answer: C

Rationale: The correct answer is to provide standby assistance when the client gets out of bed. Lisinopril can cause hypotension, especially after the first dose, which can lead to dizziness and falls. Standby assistance helps prevent potential injury. Placing the client on cardiac monitoring (choice A) or monitoring oxygen saturation (choice B) are not typically necessary after the first dose of lisinopril unless specific symptoms are present. Encouraging foods high in potassium (choice D) is not directly related to the immediate concern of postural hypotension associated with lisinopril.

5. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which action should the nurse take?

• A. Massage the affected extremity
• B. Elevate the affected leg
• C. Apply cold packs to the affected leg
• D. Keep the leg dependent to increase circulation

Correct answer: B

Rationale: Elevating the leg promotes venous return and reduces swelling, which is crucial for clients with DVT. Massaging the affected extremity can dislodge the clot and worsen the condition. Applying cold packs can cause vasoconstriction, potentially increasing the risk of clot formation. Keeping the leg dependent can impede circulation and increase the risk of clot migration.

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