Nursing Elites

1. The nurse is completing a nutritional assessment on a client. Which statement made by the client is most concerning to the nurse?

• A. "I notice when I take a vitamin E supplement, I bruise more easily."
• B. "I work nights and rarely go outside during the day."
• C. "I take warfarin, so I need to limit the amount of green leafy vegetables I eat."
• D. "My vitamin supplement has the recommended daily allowance of vitamin A."

Correct answer: A

Rationale: The correct answer is A. Excessive intake of vitamin E can increase the risk of bleeding as it acts as a blood thinner. Bruising easily may indicate too much vitamin E. Choice B is not as concerning as it describes a lifestyle that may lead to vitamin D deficiency due to lack of sunlight exposure. Choice C shows awareness of the interaction between warfarin and vitamin K, which is expected. Choice D indicates knowledge of the vitamin A content in the supplement, which is not a cause for concern.

2. Mario listens to Richard’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be:

• A. Client lying on his back then flat on his abdomen on Trendelenburg position
• B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his
• C. Client lying flat on his back and then flat on his abdomen
• D. Client lying on his right then left side on Trendelenburg position

Correct answer: A

Rationale: Proper patient positioning is essential for maximizing lung expansion and promoting the drainage of secretions. Postural drainage techniques rely on gravity to help clear different lung segments, which is critical in preventing complications such as atelectasis or pneumonia in immobilized patients.

3. What action should the nurse take first for a client with Listeria food poisoning?

• A. Educate the client on safe food practices.
• B. Start a traceback to identify the source of the outbreak.
• C. Report the case to the county board of health.
• D. Ask the client if they have consumed any unpasteurized products.

Correct answer: D

Rationale: Identifying the source of Listeria is crucial for preventing further cases.

4. Instruction on health promotion regarding urinary elimination is important. Which would you include?

• A. Hold urine as long as possible before emptying the bladder to strengthen the sphincter muscles
• B. If a burning sensation is experienced while voiding, drink water
• C. After urination, wipe from the anal area towards the pubis
• D. Tell the client to empty the bladder at each voiding

Correct answer: D

Rationale: The correct answer is to instruct the client to empty the bladder at each voiding. This is essential to prevent urinary retention and reduce the risk of urinary tract infections. Choice A is incorrect because holding urine for prolonged periods can lead to urinary retention and increase the risk of infections. Choice B is incorrect as pineapple juice can exacerbate a burning sensation due to its acidity; the correct approach is to drink water to dilute the urine. Choice C is incorrect as wiping from the anal area towards the pubis can introduce bacteria into the urinary tract, potentially causing infections.

5. A nurse is reinforcing teaching about food choices with the mother of an 8-month-old infant. Which of the following statements by the mother indicates a need for further teaching?

• A. I will give my child strained carrots and mashed egg yolks.
• B. I will give my child rice cereal and crackers.
• C. I will give my child pureed liver and strained pears.
• D. I will give my child applesauce and green peas.

Correct answer: B

Rationale: Choice B, 'I will give my child rice cereal and crackers,' indicates a need for further teaching. Infants should not be given crackers at 8 months of age due to the risk of choking. Rice cereal is appropriate for infants, but it should be introduced carefully to avoid digestive issues. Choices A, C, and D are appropriate food choices for an 8-month-old infant, providing a variety of nutrients and textures suitable for their age and developmental stage.

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