Nursing Elites

1. A client with lactose intolerance needs to increase calcium intake. Which food should the nurse recommend?

• A. Spinach
• B. Peanut butter
• C. Ground beef
• D. Carrots

Correct answer: A

Rationale: Spinach is a suitable choice to recommend for increasing calcium intake to a client with lactose intolerance. Spinach is a good non-dairy source of calcium. Peanut butter, ground beef, and carrots are not significant sources of calcium. Peanut butter is high in protein and fats, ground beef is a source of protein and iron, and carrots are rich in vitamin A and fiber, but none of these choices provide a substantial amount of calcium.

2. A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?

• A. Maintain an eye mask over the newborn's eyes
• B. Feed the newborn every hour
• C. Monitor the newborn's temperature
• D. Administer vitamin K

Correct answer: A

Rationale: During phototherapy for a newborn with hyperbilirubinemia, it is crucial to maintain an eye mask over the newborn's eyes. The purpose of the eye mask is to protect the infant's eyes from potential damage caused by the intense light used in phototherapy. While feeding the newborn frequently and monitoring temperature are essential aspects of newborn care, they are not specific to phototherapy. Administering vitamin K is important for newborns to prevent bleeding disorders but is not directly related to phototherapy for hyperbilirubinemia.

3. A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?

• A. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10
• B. Administer oxygen to a client who has an oxygen saturation of 91%
• C. Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises
• D. Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery

Correct answer: B

Rationale: When using the ABC approach to client care, the nurse should identify that the priority intervention is administering oxygen. In this scenario, the client's oxygen saturation is only 91%, which is below the normal range of 95% and above. Oxygen is essential for adequate tissue perfusion and oxygenation of vital organs. Administering oxygen takes precedence over other interventions to ensure the client's physiological needs are met first. Choice A can be addressed after ensuring adequate oxygenation. Choice C is important for preventing postoperative complications but is not as urgent as addressing oxygen saturation. Choice D is a common postoperative intervention, but in this case, ensuring adequate oxygenation is the priority over IV fluid administration.

4. A client with a new prescription for an albuterol metered-dose inhaler is being taught by a nurse. Which of the following instructions should the nurse include in the teaching?

• A. Inhale quickly when using the inhaler.
• B. Hold your breath for 10 seconds after inhaling the medication.
• C. Take a second puff of the inhaler immediately after the first.
• D. Exhale fully after using the inhaler.

Correct answer: B

Rationale: The correct instruction is to hold your breath for 10 seconds after inhaling the medication. This allows the medication to settle in the lungs and maximize its effectiveness. Choice A is incorrect as inhaling quickly may lead to improper medication delivery. Choice C is wrong because taking a second puff immediately after the first without waiting for the prescribed interval may cause an overdose. Choice D is also incorrect as exhaling fully after using the inhaler may result in the medication being exhaled rather than absorbed by the lungs.

5. A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider?

• A. The dressing was changed 7 days ago
• B. The circumference of the client’s upper arm has increased by 10%
• C. The catheter has not been used in 8 hours
• D. The catheter has been flushed with 10 mL of sterile saline after medication use

Correct answer: B

Rationale: The correct answer is B. The circumference of the upper arm above the insertion site of the PICC should be measured at the time of insertion and then again during assessments. An increase in circumference could indicate deep vein thrombosis, which could be life-threatening. Choice A is not a concern as changing the dressing 7 days ago is within the recommended timeframe. Choice C is not alarming as the catheter not being used for 8 hours does not necessarily indicate a problem. Choice D indicates proper catheter care by flushing it with sterile saline after medication use, so it does not require provider notification.

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