Nursing Elites

1. The nurse is providing discharge teaching to a client with hypertension. Which of these statements made by the client indicates an understanding of the teaching?

• A. I will limit my intake of high-sodium foods.
• B. I will take my medications as prescribed by my healthcare provider.
• C. I will monitor my blood pressure regularly and keep a record to show my healthcare provider.
• D. I will limit my intake of high-fat foods.

Correct answer: A

Rationale: The correct answer is A because limiting high-sodium foods is essential in managing hypertension and preventing complications. High sodium intake can lead to increased blood pressure levels. Choice B is important too, but solely relying on medications without lifestyle modifications may not be as effective in controlling hypertension. Choice C is also crucial for monitoring progress, but without dietary changes, blood pressure control may be challenging. Choice D, limiting high-fat foods, is beneficial for overall health but is not as directly related to managing hypertension as limiting high-sodium foods.

2. The nurse assesses a 72-year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?

• A. Decreased urinary output
• B. Jugular vein distention
• C. Pleural effusion
• D. Bibasilar crackles

Correct answer: B

Rationale: In right-sided congestive heart failure, the nurse would anticipate finding jugular vein distention. This occurs due to increased venous pressure, leading to the distention of the jugular veins in the neck. Choices A, C, and D are incorrect. Decreased urinary output is not typically associated with right-sided heart failure; pleural effusion and bibasilar crackles are more commonly seen in conditions like left-sided heart failure.

3. A healthcare professional is preparing to administer an enteral feeding via an established NG tube. Which option is not part of the sequence the healthcare professional should follow to initiate the feeding?

• A. Verify tube placement
• B. Check the residual feeding contents
• C. Administer the feeding
• D. Limit protein intake

Correct answer: D

Rationale: The correct sequence for initiating enteral feeding includes verifying tube placement to ensure safety, checking the residual feeding contents to prevent complications, and then administering the feeding. Limiting protein intake is not a step in the sequence for initiating enteral feeding. Protein intake may be adjusted based on the patient's specific nutritional needs, but it is not a part of the immediate sequence for initiating the feeding. Therefore, option D is the correct answer. Options A, B, and C are essential steps to ensure the safe and effective administration of enteral feeding.

4. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?

• A. Clamp the chest tube
• B. Call the surgeon immediately
• C. Prepare for blood transfusion
• D. Continue to monitor the rate of drainage

Correct answer: D

Rationale: In this scenario, the most appropriate nursing action is to continue to monitor the rate of drainage. Clamping the chest tube is not recommended as it can lead to a tension pneumothorax. Calling the surgeon immediately may not be necessary at this point unless the drainage rate significantly increases or other concerning symptoms develop. Preparing for a blood transfusion is premature without further assessment and monitoring of the client's condition. Monitoring the rate of drainage allows the nurse to assess for any potential complications and ensure that the drainage amount is within expected limits.

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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