Nursing Elites

1. A nurse is reinforcing teaching with a client who has constipation about a high-fiber diet. Which of the following foods should be included as sources of fiber? Select one that doesn't apply.

• A. Kidney beans
• B. Strawberries
• C. Peanut butter
• D. Whole wheat bread

Correct answer: C

Rationale: The correct answer is C, Peanut butter. While kidney beans, strawberries, and whole wheat bread are high-fiber foods that help alleviate constipation, peanut butter is not a significant source of fiber. Peanut butter is more known for its protein and healthy fats content rather than being a good source of dietary fiber. Therefore, it should not be included as a primary recommendation for a high-fiber diet in the context of addressing constipation.

2. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?

• A. Institute seizure precautions
• B. Monitor neurologic status every hour
• C. Place in respiratory/secretion precautions
• D. Cefotaxime IV 50 mg/kg/day divided q6h

Correct answer: C

Rationale: The correct answer is to place the child in respiratory/secretion precautions first. Meningococcal meningitis is highly contagious, and respiratory precautions are essential to prevent the spread of the infection. Seizure precautions may be necessary but are not the priority upon admission. Monitoring neurologic status is important but not the initial action needed. While antibiotic therapy like Cefotaxime is crucial, implementing isolation precautions to prevent transmission takes precedence in this situation.

3. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to

• A. Call the health care provider immediately
• B. Administer acetaminophen as ordered as this is normal at this time
• C. Send blood, urine, and sputum for culture
• D. Increase the client's fluid intake

Correct answer: B

Rationale: In this scenario, the nurse should administer acetaminophen as ordered because a slight fever is normal after an MI. This intervention can help manage the fever unless other complications are present. Calling the health care provider immediately is not necessary for a slight fever post-MI. Sending blood, urine, and sputum for culture is not indicated solely based on a slight fever without other symptoms or signs of infection. Increasing fluid intake may be beneficial for various reasons but is not the priority in this situation where managing the fever with acetaminophen is appropriate.

4. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

• A. Presence of blood in stools
• B. Oozing liquid stool
• C. Continuous rumbling flatulence
• D. Absence of bowel movements

Correct answer: B

Rationale: The correct answer is B: 'Oozing liquid stool.' In a paralyzed client, oozing liquid stool is a common sign of fecal impaction. This occurrence requires prompt intervention to prevent complications. Choice A, 'Presence of blood in stools,' is more indicative of gastrointestinal bleeding rather than fecal impaction. Choice C, 'Continuous rumbling flatulence,' is associated with gas movement in the intestines and not specifically linked to fecal impaction. Choice D, 'Absence of bowel movements,' could be a sign of constipation but does not directly point towards fecal impaction.

5. A nurse is providing care to a 63-year-old client with pneumonia. Which intervention promotes the client's comfort?

• A. Increase oral fluid intake
• B. Encourage visits from family and friends
• C. Keep conversations short
• D. Monitor vital signs frequently

Correct answer: C

Rationale: Keeping conversations short is the most appropriate intervention to promote comfort for a client with pneumonia. Pneumonia can be physically exhausting, and limiting the length of conversations helps conserve the client's energy. Encouraging visits from family and friends (Choice B) may be emotionally supportive but might not directly promote comfort in the context of conserving energy during recovery. Increasing oral fluid intake (Choice A) is important for hydration but may not directly address the client's comfort. Monitoring vital signs frequently (Choice D) is essential for assessing the client's condition but does not directly promote comfort.

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