Nursing Elites

1. A nurse is assessing a client who is at risk for falls. Which of the following findings should the nurse recognize as increasing the client's risk of falling?

• A. Normal gait
• B. Recent history of dizziness
• C. 20/20 vision
• D. Takes a multivitamin daily

Correct answer: B

Rationale: The correct answer is B: Recent history of dizziness. A recent history of dizziness significantly increases the risk of falling, as dizziness can impair balance and coordination. Having a normal gait (choice A) and 20/20 vision (choice C) are not factors that directly increase the risk of falling. Taking a multivitamin daily (choice D) does not inherently contribute to an increased risk of falling unless it causes dizziness as a side effect, which is not specified in the question.

2. A client with lactose intolerance needs to increase calcium intake. Which food should the nurse recommend?

• A. Spinach
• B. Peanut butter
• C. Ground beef
• D. Carrots

Correct answer: A

Rationale: Spinach is a suitable choice to recommend for increasing calcium intake to a client with lactose intolerance. Spinach is a good non-dairy source of calcium. Peanut butter, ground beef, and carrots are not significant sources of calcium. Peanut butter is high in protein and fats, ground beef is a source of protein and iron, and carrots are rich in vitamin A and fiber, but none of these choices provide a substantial amount of calcium.

3. A nurse is teaching a client about the use of alendronate. Which of the following should be included in the teaching?

• A. Take it with food
• B. Sit upright for at least 30 minutes after taking it
• C. It can be taken at bedtime
• D. It is safe to take with antacids

Correct answer: B

Rationale: The correct answer is B: 'Sit upright for at least 30 minutes after taking it.' Alendronate can cause esophageal irritation and to reduce the risk of this side effect, clients should be instructed to sit upright for at least 30 minutes after administration. Choice A is incorrect as alendronate should be taken on an empty stomach, usually in the morning, at least 30 minutes before the first food, beverage, or medication of the day. Choice C is incorrect because alendronate should not be taken at bedtime, as the client should remain upright for at least 30 minutes after taking it. Choice D is incorrect as antacids can interfere with the absorption of alendronate, so they should not be taken together.

4. A nurse is caring for a client who has a new prescription for an antidepressant. The client reports experiencing dry mouth. Which of the following instructions should the nurse give the client?

• A. Decrease fluid intake.
• B. Chew sugarless gum.
• C. Avoid using mouthwash.
• D. Increase intake of dairy products.

Correct answer: B

Rationale: The correct answer is to instruct the client to chew sugarless gum. Chewing sugarless gum can help alleviate dry mouth by stimulating saliva production, which is a common side effect of many antidepressants. Decreasing fluid intake (choice A) is not recommended as it can worsen dry mouth. Avoiding mouthwash (choice C) is not as effective as chewing gum in stimulating saliva. Increasing intake of dairy products (choice D) is not directly related to managing dry mouth caused by antidepressants.

5. A nurse in the emergency department is caring for a patient who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the patient’s care, the nurse should identify which of the following risks as the priority for assessment and intervention?

• A. Infection
• B. Airway obstruction
• C. Fluid imbalance
• D. Pain management

Correct answer: B

Rationale: When a patient has extensive burns involving the head, neck, and chest, the priority concern is airway obstruction. The proximity of the burns to the airway can lead to swelling and compromise the patient's ability to breathe. In this situation, ensuring a clear airway and adequate oxygenation takes precedence over other risks such as infection, fluid imbalance, or pain management. While these are also important considerations in burn care, the immediate threat to the patient's life from airway compromise makes it the priority for assessment and intervention.

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