Nursing Elites

1. A nurse is caring for a client with celiac disease. Which food should be removed from the meal tray?

• A. Cornbread
• B. Mashed potatoes
• C. Lentils
• D. Tortillas

Correct answer: D

Rationale: The correct answer is D, Tortillas. Clients with celiac disease should avoid gluten, which is often found in tortillas. Cornbread, mashed potatoes, and lentils are gluten-free options, making them safe for individuals with celiac disease. Therefore, the other choices (A, B, and C) do not need to be removed from the meal tray.

2. A nurse is assessing a client with pericarditis. Which of the following findings is the priority for the nurse to report?

• A. Paradoxical pulse
• B. Dependent edema
• C. Pericardial friction rub
• D. Substernal chest pain

Correct answer: A

Rationale: A paradoxical pulse is a sign of cardiac tamponade, a life-threatening complication of pericarditis that requires immediate intervention. It results from decreased cardiac output due to increased pressure in the pericardial sac. Reporting this finding promptly allows for timely treatment to prevent further deterioration. Dependent edema and substernal chest pain are common in pericarditis but are not as urgent as a paradoxical pulse. A pericardial friction rub is a classic finding in pericarditis and indicates inflammation but is not as critical as a paradoxical pulse.

3. A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?

• A. Place the infant under a radiant warmer
• B. Move the probe site every 3 hours
• C. Heat the skin one minute prior to placing the probe
• D. Place the sensor on the index finger

Correct answer: B

Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures more accurate monitoring of oxygen saturation. Placing the infant under a radiant warmer (choice A) is unnecessary and not related to pulse oximetry. Heating the skin before placing the probe (choice C) can lead to burns and is not recommended. Placing the sensor on the index finger (choice D) is not appropriate for continuous monitoring in infants.

4. A nurse is preparing to insert an indwelling urinary catheter into a female client. Which of the following actions should the nurse take?

• A. Inflate the balloon with 10 mL of sterile water prior to insertion
• B. Cleanse the client’s labia and meatus using a front-to-back motion
• C. Ask the client to bear down while inserting the catheter
• D. Inflate the catheter balloon after urine begins to flow

Correct answer: D

Rationale: The correct action for the nurse to take when inserting an indwelling urinary catheter into a female client is to inflate the catheter balloon after urine begins to flow. Inflating the balloon before urine starts flowing can lead to incorrect placement in the urethra, causing trauma. Cleansing the labia and meatus should be done before the insertion, but the crucial step of inflating the balloon should occur after the catheter is correctly placed. Asking the client to bear down is not necessary during catheter insertion.

5. A nurse is caring for a client with Alzheimer's disease. Which action should the nurse include in the care plan to support the client’s cognitive function?

• A. Place a daily calendar in the kitchen
• B. Replace buttoned clothing with zippered items
• C. Replace carpet with hardwood floors
• D. Create variation in the daily routine

Correct answer: A

Rationale: Placing a daily calendar in the kitchen is beneficial for clients with Alzheimer's disease as it helps in orienting them to time and enhances cognitive function. This visual aid can assist in keeping track of days and activities. Choice B, replacing buttoned clothing with zippered items, is more related to promoting independence in dressing rather than directly supporting cognitive function. Choice C, replacing carpet with hardwood floors, focuses on safety and mobility rather than cognitive function. Choice D, creating variation in the daily routine, may be helpful for engagement and stimulation but does not directly address cognitive function as effectively as using a daily calendar.

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