Nursing Elites

1. Vitamin deficiencies, especially the B-complex vitamins, seldom occur in isolation. Folate, a B-complex vitamin, is the exception because it functions separately from other vitamins.

• A. Both statements are true.
• B. Both statements are false.
• C. The first statement is true; the second is false.
• D. The first statement is false; the second is true.

Correct answer: C

Rationale: The first statement is true; the second is false. If a deficiency of one vitamin is suspected, symptoms of other vitamin B deficiencies also may be present. Folate deficiencies usually occur with other nutrient deficiencies. Specifically, folate functions in conjunction with vitamins B12 and C in maintaining normal levels of mature red blood cells.

2. During the Emergent phase of a burn, the most fatal electrolyte imbalance in a burned client is:

• A. Hypokalemia
• B. Hyperkalemia
• C. Hypernatremia
• D. Hyponatremia

Correct answer: A

Rationale: During the Emergent phase of burns, the most fatal electrolyte imbalance is Hypokalemia. This is due to the shift of potassium from the intracellular space to the extracellular space, leading to low potassium levels in the blood. Choices B, C, and D are incorrect because Hyperkalemia, Hypernatremia, and Hyponatremia are not typically associated with the Emergent phase of burns and do not pose the same level of risk as Hypokalemia in this context.

3. In taking the client’s blood pressure, the nurse should position the client’s arm:

• A. At the level of the heart
• B. Slightly above the level of the heart
• C. At the 5th intercostals space midclavicular line
• D. Below the level of the heart

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.

4. Where should a nurse auscultate the apex beat?

• A. At the fifth intercostal space, along the midclavicular line
• B. At the mid-sternum
• C. 2 inches to the left of the lower end of the sternum
• D. 1 inch to the left of the xiphoid process

Correct answer: A

Rationale: The correct location to auscultate the apex beat is at the fifth intercostal space, along the midclavicular line. This is where the apical impulse, also known as the point of maximal impulse (PMI), can be best heard. Choices B, C, and D are incorrect anatomical locations for auscultating the apex beat, which makes them incorrect choices. Auscultating at the correct location allows healthcare providers to assess the heart's function and detect any abnormalities in heart sounds, which is crucial for comprehensive patient care.

5. A client with chronic kidney disease is being taught about dietary needs by a nurse. Which of the following foods should the nurse identify as being the lowest in phosphorus?

• A. Medium apple
• B. Bran cereal
• C. Scrambled eggs
• D. Ground turkey

Correct answer: A

Rationale: The correct answer is A, a medium apple. Apples are a suitable option for clients with chronic kidney disease as they are low in phosphorus. Bran cereal (choice B), scrambled eggs (choice C), and ground turkey (choice D) are all higher in phosphorus content compared to apples, making them less ideal choices for individuals with chronic kidney disease.

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