Nursing Elites

1. A nurse is providing teaching to a client who has osteoporosis. Which of the following instructions should the nurse include?

• A. Take a calcium supplement once daily.
• B. Walk for 30 minutes three times per week.
• C. Avoid weight-bearing exercises.
• D. Increase intake of vitamin D.

Correct answer: B

Rationale: The correct answer is B. Walking regularly is beneficial for clients with osteoporosis as it helps maintain bone density and prevent fractures. Choice A is not the most appropriate because clients with osteoporosis often require more than just calcium supplements. Choice C is incorrect as weight-bearing exercises actually help strengthen bones. Choice D is important, but walking regularly has a more direct impact on bone health in clients with osteoporosis.

2. A client who is receiving continuous enteral feedings through a nasogastric tube needs preventive measures to avoid aspiration. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30 degrees.
• B. Check gastric residual volumes every 4 hours.
• C. Administer the feeding at room temperature.
• D. Flush the feeding tube with 20 mL of water every 8 hours.

Correct answer: B

Rationale: The correct answer is to check gastric residual volumes every 4 hours. This action helps prevent aspiration by ensuring the stomach is emptying properly, reducing the risk of reflux and aspiration. Elevating the head of the bed to 30 degrees can help prevent aspiration by promoting proper digestion and reducing the risk of regurgitation. Administering the feeding at room temperature is important for patient comfort but does not directly prevent aspiration. Flushing the feeding tube with water every 8 hours is important for tube patency but does not directly prevent aspiration.

3. A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse report to the provider immediately?

• A. Increased appetite
• B. Productive cough with green sputum
• C. Cyanosis of the lips and nail beds
• D. Mild shortness of breath

Correct answer: C

Rationale: The correct answer is C: Cyanosis of the lips and nail beds. Cyanosis is a late sign of hypoxia and indicates severe oxygen deprivation, requiring immediate intervention in clients with pneumonia. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and D are incorrect because increased appetite, productive cough with green sputum, and mild shortness of breath are common findings in clients with pneumonia and may not require immediate intervention unless they worsen or are accompanied by other concerning symptoms.

4. What is the most important nursing assessment post-surgery?

• A. Monitor vital signs
• B. Monitor blood pressure
• C. Monitor the surgical site
• D. Monitor the incision site

Correct answer: A

Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs encompass various parameters like blood pressure, heart rate, respiratory rate, and temperature. Monitoring vital signs helps in early detection of complications such as hemorrhage, infection, or shock. While monitoring the surgical site and incision site are also essential post-surgery, monitoring vital signs takes precedence as it provides a broader assessment of the patient's overall condition. Monitoring blood pressure is part of vital sign assessment and is not the most comprehensive assessment post-surgery.

5. A nurse is caring for a client who is at 28 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 120/80 mm Hg
• B. Weight gain of 0.9 kg (2 lb) in 1 week
• C. Urine output of 30 mL/hr
• D. Respiratory rate 16/min

Correct answer: B

Rationale: A weight gain of 0.9 kg (2 lb) in 1 week is an indication of fluid retention, which is concerning in a client with preeclampsia. This can be a sign of worsening condition requiring immediate medical attention. High blood pressure (option A) is expected in preeclampsia, a urine output of 30 mL/hr (option C) is decreased but not as urgent as the weight gain in this scenario, and a respiratory rate of 16/min (option D) is within normal limits.

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