Nursing Elites

1. A nurse is reinforcing dietary teaching with a client who has iron deficiency anemia. The nurse should explain that which of the following food sources contains iron that is most easily absorbed by the body?

• A. Spinach
• B. Dried apricots
• C. Chicken
• D. Lentils

Correct answer: C

Rationale: The correct answer is C, 'Chicken.' Heme iron from animal sources, such as chicken, is more easily absorbed by the body compared to non-heme iron from plant sources like spinach, dried apricots, and lentils. While plant-based iron sources are beneficial, they are not as readily absorbed by the body as heme iron from animal products.

2. After surgery, a client has been taken off the ventilator and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

• A. Allow the client to melt ice chips in the mouth
• B. Provide mints to freshen the breath
• C. Perform frequent oral care with a tooth sponge
• D. Swab the mouth with glycerin swabs

Correct answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this situation. It helps maintain oral hygiene, prevent dryness, and provide comfort for a client with an NG tube. Allowing the client to melt ice chips may not be suitable immediately post-surgery due to potential risks. Providing mints or swabbing the mouth with glycerin swabs may not address the need for proper oral care and hygiene, which is essential for a client with an NG tube.

3. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?

• A. diaphoresis with decreased urinary output
• B. increased heart rate with increased respirations
• C. improved respiratory status and increased urinary output
• D. decreased chest pain and decreased blood pressure

Correct answer: C

Rationale: When evaluating the therapeutic effectiveness of digoxin in a client with heart failure, the nurse should expect to find improved respiratory status and increased urinary output. Digoxin helps improve cardiac output and reduces fluid accumulation, leading to improved breathing and increased urinary output. Choices A, B, and D are incorrect because diaphoresis with decreased urinary output, increased heart rate with increased respirations, and decreased chest pain with decreased blood pressure are not indicative of the therapeutic effectiveness of digoxin in heart failure management.

4. A client with a history of coronary artery disease is admitted with chest pain. Which of these findings would be most concerning to the nurse?

• A. Blood pressure of 130/80 mm Hg
• B. Respiratory rate of 20 breaths per minute
• C. Heart rate of 72 beats per minute
• D. Temperature of 98.6 degrees Fahrenheit

Correct answer: B

Rationale: The correct answer is B. A respiratory rate of 20 breaths per minute may indicate respiratory distress in a client with chest pain. In a client with a history of coronary artery disease presenting with chest pain, signs of respiratory distress can be an alarming finding. Blood pressure within the normal range (130/80 mm Hg), heart rate of 72 beats per minute, and a temperature of 98.6 degrees Fahrenheit are generally considered within normal limits and may not be as concerning in this context.

5. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is

• A. Heart rate
• B. Pedal pulses
• C. Lung sounds
• D. Pupil responses

Correct answer: D

Rationale: Assessing pupil responses is crucial in a client with hypertensive crisis to monitor for signs of increased intracranial pressure, which can indicate potential neurological complications. While heart rate, pedal pulses, and lung sounds are important assessments, they do not take precedence over neurological assessments in this critical situation.

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