Nursing Elites

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

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

Correct answer: B

Rationale: The correct answer is B: Oranges. Oranges are not a rich source of iron. Iron-rich foods include liver, leafy green vegetables, and kidney beans. Oranges are a good source of vitamin C but are not high in iron. Therefore, if the client selects oranges as an iron-rich food, it indicates a need for additional instructions on choosing foods high in iron.

2. A client is receiving a continuous infusion of normal saline at 125 ml/hour post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. Urine output is 800 ml over the past 24h with a central venous pressure of 15 mmHg. The nurse notes respiratory crackle and bounding central pulses. Vital signs: temperature 101.2°F, Heart rate 96 beats/min, Respirations 24 breaths/min, and Blood pressure 160/90 mmHg. Which interventions should the nurse implement first?

• A. Review the last administration of IV pain medication.
• B. Administer a PRN dose of acetaminophen.
• C. Decrease IV fluids to keep the vein open (KVO) rate.
• D. Calculate total intake and output.

Correct answer: C

Rationale: The correct answer is to decrease IV fluids to the keep vein open (KVO) rate. The client is showing signs of fluid volume excess, such as drowsiness, headache, elevated CVP, crackles, bounding pulses, and increased blood pressure. Decreasing the IV fluids will help prevent further fluid overload. Reviewing the last administration of IV pain medication (Choice A) may be necessary but addressing the fluid balance issue is the priority. Administering a PRN dose of acetaminophen (Choice B) may help with the headache but does not address the underlying fluid overload. Calculating total intake and output (Choice D) is important but does not directly address the immediate issue of fluid overload and its associated symptoms.

3. A male client with acquired immune deficiency syndrome (AIDS) and Pneumocystis carinii pneumonia has a CD4+ T cell count of 200 cells/microliter. The client asks the nurse why he keeps getting these massive infections. Which pathophysiologic mechanism should the nurse describe in response to the client's question?

• A. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
• B. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.
• C. The humoral immune response lacks B cells that form antibodies and opportunistic infections result.
• D. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages.

Correct answer: D

Rationale: With a CD4+ T cell count of 200 cells/microliter, the client's immune system is severely compromised, leading to opportunistic infections.

4. A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. What would be the correct action by the nurse?

• A. Restrain the child in the tent and notify the health care provider.
• B. Increase the oxygen concentration in the tent.
• C. Take the child out of the tent and into the playroom.
• D. Ask the mother for help in comforting the child.

Correct answer: B

Rationale: The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation. The child should not be taken out of the oxygenated tent. While the mother could be asked to help comfort the child, and the health care provider may be notified, the priority is to set the oxygen at the correct level.

5. Which is a priority nursing intervention for the cognitively impaired child?

• A. The family will provide good nutrition.
• B. The family will provide loving interactions.
• C. Stimulation will improve.
• D. There will be contact with peers.

Correct answer: B

Rationale: The correct answer is B because nursing interventions for cognitively impaired children prioritize promoting loving interactions with family. This support helps in creating a nurturing environment that contributes to the child's well-being and development. Choice A is not the priority as good nutrition, though important, may not address the immediate emotional and social needs of the child. Choice C is vague and does not specify how stimulation will be provided. Choice D, contact with peers, is also valuable but not as crucial as the primary relationships and interactions within the family unit for a cognitively impaired child.

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