Nursing Elites

1. A nurse providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?

• A. A peanut butter sandwich on wheat bread
• B. A sliced apple and red grapes
• C. A chocolate chip cookie with a glass of skim milk
• D. A scrambled egg with cheddar cheese

Correct answer: B

Rationale: The correct answer is B. Clients with phenylketonuria (PKU) must adhere to a strict low-phenylalanine diet to prevent neurological damage. Foods high in phenylalanine such as peanut butter, wheat bread, chocolate chip cookies, milk, scrambled eggs, and cheddar cheese should be avoided. Sliced apples and red grapes are low in phenylalanine, making them safe choices for individuals with PKU. Choice A (peanut butter sandwich on wheat bread), Choice C (chocolate chip cookie with a glass of skim milk), and Choice D (scrambled egg with cheddar cheese) are all high in phenylalanine and should be avoided by individuals with PKU.

2. A healthcare professional is assessing a client for signs of depression. Which of the following findings should the healthcare professional look for?

• A. Increased energy
• B. Changes in sleep patterns
• C. Weight loss
• D. Both B and C

Correct answer: D

Rationale: When assessing a client for signs of depression, healthcare professionals should look for changes in sleep patterns and weight loss. These are common symptoms associated with depression. Increased energy (choice A) is not typically a sign of depression, as individuals with depression often experience fatigue and a lack of energy. Therefore, choices A, B, and C are incorrect, making choice D the correct answer.

3. A nurse is providing teaching about the Mediterranean diet to a client who has a new diagnosis of hypertension. Which of the following statements by the client indicates a need for further teaching?

• A. I will limit my intake of red meat to twice monthly.
• B. I can have dairy in moderate portions daily.
• C. I can have fish two times a week.
• D. I can drink wine in moderation.

Correct answer: A

Rationale: The correct answer is A. In the Mediterranean diet, red meat should be limited to two times monthly, not weekly. Choice B is correct as dairy in moderate portions daily is suitable for the Mediterranean diet. Choice C is also correct as having fish two times a week aligns with the Mediterranean diet. Choice D is correct as moderate wine consumption is a component of the Mediterranean diet.

4. A healthcare professional is assessing a client for signs of fluid overload. Which of the following findings should the healthcare professional look for?

• A. Weight loss
• B. Decreased blood pressure
• C. Edema
• D. Increased urine output

Correct answer: C

Rationale: Edema is a common sign of fluid overload. When the body retains more fluid than it excretes, it can lead to edema, which is swelling caused by excess fluid trapped in body tissues. Weight gain, not weight loss, is typically associated with fluid overload due to the retained fluids. Decreased blood pressure is more commonly associated with dehydration rather than fluid overload. Increased urine output is a sign of the body trying to eliminate excess fluids, which is contrary to the signs of fluid overload.

5. A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. The client reports heavy bleeding and passing large clots. What is the priority action for the nurse to take?

• A. Administer oxytocin IV
• B. Perform fundal massage
• C. Check vital signs
• D. Encourage the client to void

Correct answer: B

Rationale: Performing fundal massage is the priority action to take in this situation. Fundal massage helps stimulate uterine contractions, which can reduce postpartum bleeding. Uterine atony, the most common cause of early postpartum hemorrhage, can be addressed effectively through fundal massage. Administering oxytocin IV, although important, should come after initiating fundal massage. Checking vital signs is also crucial but not the immediate priority. Encouraging the client to void does not directly address the heavy bleeding and passing of large clots; hence, it is not the priority action.

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