Nursing Elites

1. The nurse is conducting diet teaching for a client diagnosed with hypertension. Which foods should the nurse encourage the client to eat?

• A. Pickled olives
• B. Canned soup
• C. Fresh or frozen vegetables without sauce
• D. Fruits without sauce

Correct answer: C

Rationale: The correct answer is C: Fresh or frozen vegetables without sauce. These foods are low in sodium, which is crucial for managing hypertension. Pickled olives (choice A) and canned soup (choice B) are high in sodium, which can exacerbate hypertension. While fruits without sauce (choice D) are generally healthy, emphasizing vegetables is more beneficial for hypertension due to their lower sodium content.

2. Before administering digoxin to a client with heart failure, what is the most important assessment for the nurse to perform?

• A. Check the client's blood pressure
• B. Monitor the client's heart rate
• C. Assess the client's respiratory rate
• D. Review the client's potassium level

Correct answer: B

Rationale: The correct answer is to monitor the client's heart rate. Digoxin slows the heart rate, so it is crucial to assess the heart rate before administering the medication. If the heart rate is below 60 beats per minute, the dose should be held, and the healthcare provider should be notified. Checking the blood pressure (Choice A) is important but not as crucial as monitoring the heart rate in this case. Assessing the respiratory rate (Choice C) is not directly related to the action of digoxin. Reviewing the client's potassium level (Choice D) is important for clients taking digoxin due to the risk of hypokalemia, but assessing the heart rate takes priority.

3. A client with hypocalcemia is receiving calcium gluconate. What assessment finding requires immediate intervention?

• A. Decreased deep tendon reflexes.
• B. Wheezing and stridor.
• C. Decreased bowel sounds.
• D. Positive Chvostek's sign.

Correct answer: B

Rationale: Wheezing and stridor may indicate a severe allergic reaction to calcium gluconate, such as anaphylaxis, which requires immediate intervention. While hypocalcemia can present with decreased deep tendon reflexes and positive Chvostek's sign, these findings do not indicate an immediate life-threatening situation. Decreased bowel sounds are not directly related to a severe reaction to calcium gluconate and do not require immediate intervention.

4. The nurse is caring for a client with an acute myocardial infarction. Which symptom requires immediate intervention?

• A. Dizziness
• B. Shortness of breath
• C. Severe chest pain
• D. Nausea and vomiting

Correct answer: C

Rationale: Severe chest pain is the hallmark symptom of an acute myocardial infarction (heart attack) and requires immediate intervention to prevent further damage to the heart muscle. Chest pain in this context is often described as crushing, pressure, tightness, or heaviness. It can radiate to the arms, neck, jaw, back, or upper abdomen. Other symptoms like dizziness, shortness of breath, nausea, and vomiting may also occur in acute myocardial infarction, but chest pain is the most critical sign requiring prompt action as it signifies inadequate blood flow to the heart muscle. Shortness of breath may indicate heart failure, while nausea and vomiting can be associated with the sympathetic response to myocardial infarction. Dizziness could result from decreased cardiac output but is not as specific to myocardial infarction as severe chest pain.

5. Following discharge teaching, a male client with a duodenal ulcer tells the nurse that he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?

• A. Encourage the client to drink milk
• B. Review with the client the need to avoid foods that are rich in milk and cream
• C. Instruct the client to take antacids instead
• D. Advise the client to monitor their symptoms

Correct answer: B

Rationale: The client should be advised to avoid foods rich in milk and cream. Although they provide temporary relief, dairy products, especially milk, stimulate gastric acid secretion, which can exacerbate the symptoms of a duodenal ulcer. Encouraging the client to drink milk (Choice A) would be counterproductive and could worsen the condition. Instructing the client to take antacids (Choice C) may provide symptomatic relief but does not address the root cause of the issue. Advising the client to monitor their symptoms (Choice D) is vague and does not provide specific guidance on managing the duodenal ulcer. Therefore, the best action is to review with the client the need to avoid foods rich in milk and cream to ensure proper ulcer management.

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