Nursing Elites

1. When assessing constipation in elders, which action should be the nurse's priority?

• A. Obtain a complete blood count
• B. Obtain a health and dietary history
• C. Refer to a provider for a physical examination
• D. Measure height and weight

Correct answer: B

Rationale: The correct answer is to obtain a health and dietary history when assessing constipation in elders. This action is crucial as it helps the nurse identify potential causes and contributing factors to constipation in elderly clients. Obtaining a complete blood count (choice A) may be necessary at some point, but it is not the priority in this situation. Referring to a provider for a physical examination (choice C) and measuring height and weight (choice D) are important but are not the priority actions when assessing constipation.

2. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

• A. Add a thickening agent to the fluids
• B. Check the client's gag reflex
• C. Feed the client only solid foods
• D. Increase the rate of intravenous fluids

Correct answer: B

Rationale: Checking the client's gag reflex is crucial in this situation as coughing while consuming liquids can indicate a risk of aspiration. Assessing the gag reflex can help determine if the client is safe to swallow without inhaling fluids into the lungs, which could lead to further respiratory complications. Adding a thickening agent may not address the underlying issue of aspiration risk. Feeding the client only solid foods is not appropriate without assessing the swallowing safety first. Increasing the rate of intravenous fluids does not directly address the client's difficulty with liquid intake.

3. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

• A. Disconnect the client from the ventilator and use a manual resuscitation bag
• B. Perform a quick assessment of the client's condition
• C. Call the respiratory therapist for help
• D. Press the alarm reset button on the ventilator

Correct answer: B

Rationale: When the high-pressure alarm on a ventilator goes off, the nurse's initial action should be to perform a quick assessment of the client's condition. This assessment helps in promptly identifying the cause of the alarm, such as mucus plugging, kinking of the tubing, or other issues. By assessing the client first, the nurse can determine the appropriate intervention needed to address the alarm. Choices A and D are incorrect because disconnecting the client from the ventilator or pressing the alarm reset button should not be the initial actions without assessing the client's condition. While calling the respiratory therapist for help could be beneficial, assessing the client's condition should be the nurse's priority to address the immediate concern.

4. A nurse is reinforcing teaching with a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching?

• A. Increase fluid intake by drinking bottled water.
• B. A salad bar is a healthy choice when dining out.
• C. Soft-boiled eggs are an appropriate source of protein.
• D. Eating at buffets is a good choice to increase caloric intake.

Correct answer: A

Rationale: Clients with neutropenia should avoid foods that may be contaminated to prevent infections. Increasing fluid intake is important to stay hydrated, but it's crucial to use safe sources like bottled water to reduce the risk of infection. Choices B, C, and D are not appropriate for a client with neutropenia. Salad bars may contain raw or unwashed produce, soft-boiled eggs may carry a risk of contamination, and buffets may have food items that are not recommended for someone with neutropenia.

5. When introducing solid foods to an infant, what food should be recommended to be introduced first?

• A. Strained fruits
• B. Pureed meats
• C. Cooked egg whites
• D. Iron-fortified cereal

Correct answer: D

Rationale: When introducing solid foods to infants, iron-fortified cereal is usually recommended as the first food due to its high nutritional value and the importance of iron for the baby's development. Strained fruits (choice A) are often introduced later due to their higher sugar content. Pureed meats (choice B) and cooked egg whites (choice C) are usually introduced after iron-fortified cereal to provide additional sources of protein and other nutrients.

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