Nursing Elites

1. A nurse is reinforcing dietary teaching with a client who has a burn injury and adheres to a strict vegan diet. Which of the following food choices should the nurse recommend?

• A. Tuna salad
• B. Fresh fruit
• C. Vegetables
• D. Beans

Correct answer: D

Rationale: Beans are an excellent choice for a client with a burn injury who follows a strict vegan diet. They are a rich source of protein, essential for healing, making them the most suitable option among the choices provided. Tuna salad (choice A) is not suitable for a vegan diet as it contains animal products. While fresh fruit (choice B) and vegetables (choice C) are healthy options, they may not provide sufficient protein needed for healing from a burn injury.

2. An 85-year-old client complains of generalized muscle aches and pains. What should be the nurse's first action?

• A. Assess the severity and location of the pain
• B. Obtain an order for an analgesic
• C. Reassure the client that this is not unusual for his age
• D. Encourage the client to increase activity

Correct answer: A

Rationale: The correct answer is to assess the severity and location of the pain. This is crucial because understanding the nature of the pain will guide the nurse in developing an appropriate pain management plan. Choice B is incorrect because administering analgesics should come after assessing the pain to ensure the right medication is given. Choice C is incorrect because dismissing the pain as a normal part of aging without proper assessment could overlook underlying issues. Choice D is incorrect as increasing activity without understanding the cause of pain may exacerbate the client's condition.

3. In a client with chronic kidney disease having a serum potassium level of 6.5 mEq/L, which assessment is the most critical for the nurse to perform?

• A. Neurological status
• B. Cardiac status
• C. Respiratory status
• D. Gastrointestinal status

Correct answer: B

Rationale: Corrected Rationale: Assessing cardiac status is crucial in hyperkalemia as high potassium levels can result in life-threatening arrhythmias. Monitoring the heart rhythm and ECG findings is essential to prevent cardiac complications. Neurological status, respiratory status, and gastrointestinal status are important assessments too, but in the context of hyperkalemia, cardiac status takes precedence due to the immediate risk of cardiac arrhythmias.

4. A nurse is assisting with the development of strategies to prevent foodborne illnesses for a community group. The nurse should plan to include which of the following recommendations? (Select one that doesn't apply).

• A. Avoid unpasteurized dairy products.
• B. Keep cold food temperatures below 4.4°C (40°F).
• C. Discard leftovers after 48 hours.
• D. Wash raw vegetables thoroughly in clean water.

Correct answer: C

Rationale: The correct answer is C. Discarding leftovers after 48 hours is not an effective recommendation to prevent foodborne illnesses. Leftovers should actually be discarded within 2 hours if they have been at room temperature. Choices A, B, and D are all effective strategies to prevent foodborne illnesses: avoiding unpasteurized dairy products reduces the risk of harmful bacteria, keeping cold food temperatures below 4.4°C (40°F) inhibits bacterial growth, and washing raw vegetables thoroughly removes contaminants.

5. The nurse is teaching an 87-year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID

• A. Glycerin suppositories
• B. Fiber supplements
• C. Laxatives
• D. Stool softeners

Correct answer: C

Rationale: The correct answer is C: Laxatives. Laxatives can be harsh on elderly clients, leading to dependence and potential side effects. While fiber supplements (B) and stool softeners (D) are generally safe options to promote regular bowel movements, laxatives should be used cautiously in older adults due to their potential risks. Glycerin suppositories (A) can also be a safe and effective option for managing constipation in the elderly, but laxatives should be avoided unless deemed necessary by a healthcare provider.

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