Nursing Elites

1. A nurse is assisting an adolescent client in the selection of complementary protein sources on the lunch menu. The client is a vegetarian who eats milk products but does not like beans. Which of the following food items should the nurse recommend?

• A. Peanut butter and jelly with enriched bread
• B. Baked potato with sour cream
• C. Bagel with cream cheese
• D. Fruit salad and carrot sticks

Correct answer: A

Rationale: Peanut butter and enriched bread provide complementary proteins, which are important for a vegetarian diet. Peanut butter is a good source of protein and when paired with enriched bread, it forms a complete protein source. Choice B, baked potato with sour cream, lacks complete protein. Choice C, bagel with cream cheese, also does not provide a complete protein source. Choice D, fruit salad and carrot sticks, do not contain sufficient protein to serve as a main protein source for a vegetarian diet.

2. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

• A. Exercise by doing weight-bearing activities
• B. Exercise to reduce weight
• C. Avoid exercise activities that increase the risk of fracture
• D. Exercise to strengthen muscles and thereby protect bones

Correct answer: A

Rationale: The most important instruction for a 65-year-old female client diagnosed with osteoporosis regarding exercise is to engage in weight-bearing activities. Weight-bearing exercises are crucial in maintaining bone density and preventing osteoporosis-related fractures. Choice B is incorrect because the primary focus should be on bone health rather than weight reduction. Choice C is incorrect as avoiding all exercise activities that increase the risk of fracture would limit physical activity, which is essential for overall health. Choice D is incorrect as while strengthening muscles is beneficial, weight-bearing activities directly impact bone health in osteoporosis.

3. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

• A. Sensory perceptual alterations related to decreased vision
• B. Alteration in mobility related to fatigue
• C. Impaired gas exchange related to retained secretions
• D. Altered patterns of urinary elimination related to nocturia

Correct answer: D

Rationale: The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia increases the risk of falls in elderly clients due to frequent nighttime trips to the bathroom. Choice A is incorrect because while decreased vision can contribute to falls, nocturia poses a more direct risk. Choice B is incorrect as fatigue may affect mobility but is not as directly linked to falls as nocturia. Choice C is incorrect as impaired gas exchange is not typically associated with an increased risk of falls.

4. A client is receiving total parenteral nutrition (TPN). Which of these interventions should the nurse perform to reduce the risk of infection?

• A. Changing the TPN tubing and solution every 24 hours
• B. Monitoring the TPN infusion rate closely
• C. Keeping the head of the bed elevated
• D. Ensuring the solution is at room temperature before infusing

Correct answer: A

Rationale: The correct answer is to change the TPN tubing and solution every 24 hours to reduce the risk of infection. This practice helps prevent microbial growth and contamination in the TPN solution. Monitoring the infusion rate closely (choice B) is important for preventing metabolic complications but does not directly reduce the risk of infection. Keeping the head of the bed elevated (choice C) is beneficial for preventing aspiration in feeding tube placement but is unrelated to reducing infection risk in TPN. Ensuring the solution is at room temperature before infusing (choice D) is essential for patient comfort and preventing metabolic complications but does not specifically address infection risk reduction.

5. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?

• A. diaphoresis with decreased urinary output
• B. increased heart rate with increased respirations
• C. improved respiratory status and increased urinary output
• D. decreased chest pain and decreased blood pressure

Correct answer: C

Rationale: When evaluating the therapeutic effectiveness of digoxin in a client with heart failure, the nurse should expect to find improved respiratory status and increased urinary output. Digoxin helps improve cardiac output and reduces fluid accumulation, leading to improved breathing and increased urinary output. Choices A, B, and D are incorrect because diaphoresis with decreased urinary output, increased heart rate with increased respirations, and decreased chest pain with decreased blood pressure are not indicative of the therapeutic effectiveness of digoxin in heart failure management.

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