Nursing Elites

1. A client has acute dysphagia. Which of the following nursing interventions should be included in the plan of care?

• A. Providing a straw for consumption of liquids
• B. Encouraging larger bites
• C. Placing the client in semi-Fowler's position during meals
• D. Instructing the client to tilt head forward when swallowing

Correct answer: C

Rationale: Placing the client in semi-Fowler's position during meals is the correct intervention for a client with acute dysphagia. This position helps prevent aspiration by facilitating swallowing. Providing a straw for consumption of liquids (Choice A) can increase the risk of aspiration and is not recommended for clients with dysphagia. Encouraging larger bites (Choice B) can also increase the risk of choking and aspiration. Instructing the client to tilt the head forward when swallowing (Choice D) is not the recommended technique for managing dysphagia as it does not address the underlying issue effectively.

2. 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.

3. A nurse is reviewing blood glucose values for a client who is at risk for Diabetes Mellitus. Which of the following findings should the nurse report to the provider?

• A. 2-hour glucose tolerance test level 150 mg/dL
• B. Fasting blood glucose 70 mg/dL
• C. Glycosylated hemoglobin 5%
• D. Casual blood glucose 90 mg/dL

Correct answer: A

Rationale: The correct answer is A. A 2-hour glucose tolerance test level of 150 mg/dL is above the normal range and should be reported to the provider as it indicates impaired glucose tolerance. Choice B (Fasting blood glucose 70 mg/dL) is within the normal range. Choice C (Glycosylated hemoglobin 5%) is also within the normal range. Choice D (Casual blood glucose 90 mg/dL) is within the normal range and does not indicate impaired glucose tolerance.

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 group of clients is being instructed by a nurse regarding nutrition. The teaching should state that which of the following groups of foods contains the highest level of carbohydrates?

• A. Milk, eggs, and cheese
• B. Butter, oils, and avocados
• C. Rice, potatoes, and oranges
• D. Chicken, green beans, and apples

Correct answer: C

Rationale: The correct answer is C: Rice, potatoes, and oranges. These foods are rich in carbohydrates. Choice A (Milk, eggs, and cheese) contains minimal carbohydrates as they are primarily sources of protein and fat. Choice B (Butter, oils, and avocados) contains very little to no carbohydrates as they are high in fats. Choice D (Chicken, green beans, and apples) also contains minimal carbohydrates, with protein and fiber being more prominent in these foods.

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