Nursing Elites

1. The nurse is caring for a client with a history of peptic ulcer disease. Which of these findings would be most concerning to the nurse?

• A. A heart rate of 72 beats per minute
• B. A hemoglobin level of 12 g/dL
• C. The client reports black, tarry stools
• D. The client reports nausea and vomiting

Correct answer: C

Rationale: Black, tarry stools can indicate gastrointestinal bleeding, which is a serious complication of peptic ulcer disease. This finding suggests active bleeding in the gastrointestinal tract, requiring immediate attention. A normal heart rate of 72 beats per minute (choice A) is within the expected range. A hemoglobin level of 12 g/dL (choice B) is also within normal limits. Nausea and vomiting (choice D) are common symptoms associated with peptic ulcer disease but may not necessarily indicate active bleeding like black, tarry stools.

2. A nurse is reinforcing teaching with a client who has constipation about a high-fiber diet. Which of the following foods should be included as sources of fiber? Select one that doesn't apply.

• A. Kidney beans
• B. Strawberries
• C. Peanut butter
• D. Whole wheat bread

Correct answer: C

Rationale: The correct answer is C, Peanut butter. While kidney beans, strawberries, and whole wheat bread are high-fiber foods that help alleviate constipation, peanut butter is not a significant source of fiber. Peanut butter is more known for its protein and healthy fats content rather than being a good source of dietary fiber. Therefore, it should not be included as a primary recommendation for a high-fiber diet in the context of addressing constipation.

3. A nurse is assisting an adolescent client in the selection of complementary protein sources on the lunch menu. The client is a vegetarian who eats milk products but does not like beans. Which of the following food items should the nurse recommend?

• A. Peanut butter and jelly with enriched bread
• B. Baked potato with sour cream
• C. Bagel with cream cheese
• D. Fruit salad and carrot sticks

Correct answer: A

Rationale: Peanut butter and enriched bread provide complementary proteins, which are important for a vegetarian diet. Peanut butter is a good source of protein and when paired with enriched bread, it forms a complete protein source. Choice B, baked potato with sour cream, lacks complete protein. Choice C, bagel with cream cheese, also does not provide a complete protein source. Choice D, fruit salad and carrot sticks, do not contain sufficient protein to serve as a main protein source for a vegetarian diet.

4. After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate?

• A. 3 oz. broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
• B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
• C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
• D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

Correct answer: D

Rationale: The correct answer is D. A meal of turkey, sweet potato, green beans, milk, and an orange is low in sodium and suitable for a post-MI diet. Choice A includes a baked potato and canned beets, which are higher in sodium. Choice B includes canned salmon, which can be high in sodium. Choice C includes a bologna sandwich, which is also high in sodium compared to the other options.

5. During a physical assessment on a client who just had an endotracheal tube inserted, which finding would call for immediate action by the nurse?

• A. Breath sounds are auscultated bilaterally
• B. Mist is visible in the T-Piece
• C. Pulse oximetry of 88%
• D. Client is unable to speak

Correct answer: C

Rationale: A pulse oximetry reading of 88% indicates hypoxemia, which requires immediate intervention to ensure adequate oxygenation. In this scenario, the priority is to address the low oxygen saturation to prevent further complications. Auscultation of bilateral breath sounds is a positive finding as it indicates air entry into both lungs. Mist in the T-piece is expected in clients with an endotracheal tube, and the inability to speak is common due to the tube's placement.

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