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. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements?

• A. The treatment requires reapplication in 8 to 10 days.
• B. Bedding and clothing can be boiled or steamed.
• C. Children are not to share hats, scarves, and combs.
• D. Nit combs are necessary to comb out nits.

Correct answer: C

Rationale: The most crucial information to prevent the spread of lice in schools is to avoid sharing hats, scarves, and combs. This is important as lice can easily spread through shared personal items. Choices A, B, and D are not as critical as choice C in preventing the spread of lice. Reapplication of treatment, boiling or steaming bedding and clothing, and using nit combs are important but not as crucial as avoiding the sharing of personal items.

3. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?

• A. The tube will drain fluid from your chest.
• B. The tube will remove excess air from your chest.
• C. The tube controls the amount of air that enters your chest.
• D. The tube will seal the hole in your lung.

Correct answer: B

Rationale: The correct answer is B: 'The tube will remove excess air from your chest.' In a spontaneous pneumothorax, air accumulates in the pleural space, causing lung collapse. The chest tube is inserted to remove this excess air, allowing the lung to re-expand. Choices A, C, and D are incorrect because the primary purpose of a chest tube in pneumothorax is to evacuate air, not fluid, control air entry, or seal a lung hole.

4. Which of these findings would the nurse most closely associate with anemia in a 10-month-old infant?

• A. Hemoglobin level of 12 g/dL
• B. Pale mucosa of the eyelids and lips
• C. Hypoactivity
• D. A heart rate between 140 to 160

Correct answer: B

Rationale: The correct answer is B. Pale mucosa of the eyelids and lips is a classic sign of anemia in infants, indicating a lack of sufficient red blood cells. This finding is due to decreased hemoglobin levels, which causes reduced oxygen delivery to tissues. Choices A, C, and D are less specific to anemia in infants. While a hemoglobin level of 12 g/dL may be within the normal range for a 10-month-old infant, the presence of pale mucosa is a more indicative sign of anemia.

5. A client with a history of deep vein thrombosis (DVT) is being treated with anticoagulants. Which of these findings is most concerning to the nurse?

• A. Presence of bruising on the arms and legs
• B. The client reports new onset of severe headache
• C. The client reports pain and swelling in the calf
• D. The client reports increased urination

Correct answer: C

Rationale: The correct answer is C because pain and swelling in the calf can indicate a new or worsening DVT, requiring immediate attention. Bruising on the arms and legs may be a common side effect of anticoagulants but is not as concerning as a potential DVT. Severe headache may indicate other conditions like a migraine or hypertension and is not directly related to DVT. Increased urination is not typically associated with DVT and may point towards other health issues like diabetes or urinary tract infections.

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