Nursing Elites

1. The client has been diagnosed with hypertension, and the nurse is providing education on dietary changes. Which food should the client be advised to avoid?

• A. Bananas
• B. Processed meats
• C. Low-fat yogurt
• D. Whole grains

Correct answer: B

Rationale: Processed meats should be avoided by clients with hypertension as they are high in sodium, which can contribute to elevated blood pressure. It is essential to limit the intake of high-sodium foods to help manage hypertension. Bananas, low-fat yogurt, and whole grains are generally beneficial for heart health due to their nutrient content and should not be avoided in a heart-healthy diet.

2. A client with chronic obstructive pulmonary disease (COPD) is admitted with increasing shortness of breath. What is the nurse's priority action?

• A. Administer oxygen via nasal cannula.
• B. Reposition the client to improve breathing.
• C. Perform chest physiotherapy.
• D. Encourage the client to cough and deep breathe.

Correct answer: A

Rationale: The correct answer is A: Administer oxygen via nasal cannula. Oxygen therapy is the priority intervention for a client with COPD experiencing increasing shortness of breath. It helps improve oxygenation and relieve respiratory distress. Choice B is not the priority as oxygenation needs to be addressed first. Choice C, chest physiotherapy, may be beneficial but is not the immediate priority in this situation. Choice D, encouraging the client to cough and deep breathe, is not the priority intervention when oxygenation is compromised.

3. An adult male is brought to the emergency department following a motorcycle accident, presenting with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?

• A. Rebound abdominal tenderness.
• B. Diminished bilateral breath sounds.
• C. Rib pain with deep inspiration.
• D. Nausea with projectile vomiting.

Correct answer: D

Rationale: In this scenario, the patient's presentation with periorbital bruising and bloody ear drainage suggests a basilar skull fracture. Projectile vomiting, as described in choice D, is concerning for increased intracranial pressure due to the skull fracture. This finding warrants immediate intervention to prevent further neurological compromise. Choices A, B, and C are not the priority in this situation. Rebound abdominal tenderness (choice A) is indicative of intra-abdominal injury but is not as urgent as managing potential intracranial issues. Diminished breath sounds (choice B) and rib pain with deep inspiration (choice C) may suggest underlying chest injuries, which need attention but are not as immediately life-threatening as increased intracranial pressure.

4. A client with acute pancreatitis is receiving nothing by mouth (NPO) status. What is the nurse's priority intervention?

• A. Administer antiemetic medication as prescribed.
• B. Monitor the client's intake and output.
• C. Provide mouth care to keep the client comfortable.
• D. Elevate the client's head of the bed.

Correct answer: B

Rationale: The correct answer is B: Monitor the client's intake and output. When a client with acute pancreatitis is on NPO status, the nurse's priority intervention is to monitor the client's intake and output. This is crucial to assess for signs of dehydration, electrolyte imbalances, and to ensure the client is responding appropriately to treatment. Administering antiemetic medication (choice A) may be necessary for managing nausea and vomiting but is not the priority over monitoring intake and output. Providing mouth care (choice C) and elevating the client's head of the bed (choice D) are important aspects of care but do not take precedence over monitoring intake and output to prevent complications in clients with NPO status due to acute pancreatitis.

5. A 5-week-old infant with hypertrophic pyloric stenosis has developed projectile vomiting over the last two weeks. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give sugar water only.
• B. Offer the infant oral rehydration every 2 hours.
• C. Provide Pedialyte feedings via nasogastric tube.
• D. Maintain intravenous fluid therapy.

Correct answer: D

Rationale: The correct intervention for a 5-week-old infant with hypertrophic pyloric stenosis presenting with projectile vomiting is to maintain intravenous fluid therapy. This is essential to maintain hydration before surgery. Instructing the mother to give sugar water only (Choice A) is inadequate and does not address the need for proper hydration. Offering oral rehydration every 2 hours (Choice B) may not be effective in cases of severe vomiting and could lead to further fluid loss. Providing Pedialyte feedings via nasogastric tube (Choice C) is an option, but in severe cases, intravenous fluid therapy is more effective in ensuring hydration and electrolyte balance.

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