Nursing Elites

1. The healthcare provider provides dietary instructions about iron-rich food to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions?

• A. Liver
• B. Kidney beans
• C. Oranges
• D. Leafy green vegetables

Correct answer: C

Rationale: Oranges are not a good source of iron, so selecting oranges indicates a need for additional instructions. Oranges are high in vitamin C, which can enhance iron absorption from other sources, but they are not rich in iron themselves. Liver, kidney beans, and leafy green vegetables are good sources of iron and would be beneficial for a client with iron deficiency anemia. Therefore, the correct answer is C.

2. A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs and symptoms of respiratory alkalosis does the nurse assess this client?

• A. Disorientation and dyspnea
• B. Drowsiness, headache, and tachypnea
• C. Tachypnea, dizziness, and paresthesias
• D. Dysrhythmias and decreased respiratory rate and depth

Correct answer: C

Rationale: The correct answer is C: Tachypnea, dizziness, and paresthesias. When a client is anxious, they may hyperventilate, leading to respiratory alkalosis. Tachypnea (rapid breathing) is a common sign of respiratory alkalosis. Dizziness and paresthesias (tingling or numbness in the extremities) are also typical symptoms. Choices A, B, and D are incorrect. Disorientation and dyspnea (Choice A) are not specific signs of respiratory alkalosis. Drowsiness, headache, and tachypnea (Choice B) may be more indicative of other conditions. Dysrhythmias and decreased respiratory rate and depth (Choice D) are not consistent with the expected signs of respiratory alkalosis.

3. A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement?

• A. Position the head of the bed (HOB) flat.
• B. Withhold intravenous fluids.
• C. Administer a bolus of IV fluids.
• D. Give an antihypertensive medication.

Correct answer: D

Rationale: In a client with a completed ischemic stroke, an elevated blood pressure like 180/90 mm Hg requires immediate intervention to prevent further damage. Giving an antihypertensive medication is essential to reduce the risk of recurrent stroke or complications related to hypertension. Positioning the head of the bed flat, withholding IV fluids, or administering a bolus of IV fluids are not appropriate actions for managing elevated blood pressure in this scenario and may not address the underlying cause of the hypertension or prevent potential complications.

4. Laboratory findings indicate that a client's serum potassium level is 2.5 mEq/L. What action should the nurse take?

• A. Inform the healthcare provider of the need for potassium replacement.
• B. Prepare to administer a glucose-insulin-potassium replacement.
• C. Change the plan of care to include hourly urinary output measurement.
• D. Instruct the client to increase daily intake of potassium-rich foods.

Correct answer: A

Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. The immediate action the nurse should take is to inform the healthcare provider of the need for potassium replacement. Option B, preparing to administer glucose-insulin-potassium replacement, is not the first-line intervention; it may be considered in specific situations but requires a healthcare provider's prescription. Option C, changing the plan of care to include hourly urinary output measurement, is not the priority when managing critically low potassium levels. Option D, instructing the client to increase daily intake of potassium-rich foods, is not appropriate in this acute situation where immediate intervention is needed to address the dangerously low potassium level.

5. A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse?

• A. White blood count of 10,000/mm³.
• B. Serum glucose of 115 mg/dL.
• C. Purulent sputum.
• D. Excessive hunger.

Correct answer: C

Rationale: The correct answer is C: Purulent sputum. Corticosteroids can suppress the immune system, increasing the risk of infections. Purulent sputum suggests a possible respiratory infection, which can rapidly progress and lead to complications, making it the most concerning finding. Choice A, a white blood count of 10,000/mm³, is within the normal range and not typically a cause for immediate concern. Choice B, a serum glucose level of 115 mg/dL, is also normal and not directly related to corticosteroid use. Choice D, excessive hunger, is a common side effect of corticosteroids but is not as concerning as a sign of infection indicated by purulent sputum.

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