Nursing Elites

1. The caregiver is teaching parents about the diet for a 4-month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include

• A. Formula or breast milk
• B. Broth and tea
• C. Rice cereal and apple juice
• D. Gelatin and ginger ale

Correct answer: A

Rationale: The correct answer is A: Formula or breast milk. In infants with gastroenteritis and mild dehydration, it is essential to continue feeding them with formula or breast milk along with oral rehydration fluids to provide adequate nutrition and maintain hydration. Option B, broth and tea, may not provide the necessary nutrients and electrolytes needed for the infant's recovery. Option C, rice cereal and apple juice, can be harsh on the digestive system and may exacerbate diarrhea. Option D, gelatin and ginger ale, do not provide the necessary nutrients and can worsen the condition due to the high sugar content in ginger ale.

2. A nurse is in a public building when someone cries out, 'Help! I think he is having a heart attack!' The nurse responds to the scene and finds the unconscious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after ensuring someone has called for EMS, should be to:

• A. Administer cardiac compressions
• B. Attach the AED pads to the client
• C. Check for a pulse
• D. Perform rescue breaths

Correct answer: A

Rationale: In a scenario where a person is unconscious and there is an indication of a possible heart attack, the immediate priority for the nurse should be to administer cardiac compressions. This action helps maintain circulation and ensures oxygenated blood reaches vital organs until the AED is available. Checking for a pulse or performing rescue breaths may delay essential circulation support, and attaching AED pads should follow the initial step of administering compressions to maximize the chances of a successful resuscitation.

3. A client is admitted with a diagnosis of left-sided heart failure. Which assessment finding would be most concerning?

• A. Peripheral edema
• B. Crackles in the lungs
• C. Jugular vein distention
• D. Hepatomegaly

Correct answer: B

Rationale: The correct answer is B: Crackles in the lungs. Crackles in the lungs indicate pulmonary congestion, a serious complication of left-sided heart failure. The presence of crackles suggests fluid accumulation in the lungs, impairing gas exchange and potentially leading to respiratory distress. Immediate intervention is necessary to prevent worsening respiratory function. Choices A, C, and D are incorrect: Peripheral edema is a common finding in heart failure but may not be as acutely concerning as pulmonary congestion. Jugular vein distention is associated with right-sided heart failure, not left-sided heart failure. Hepatomegaly is often seen in liver conditions and right-sided heart failure, not specifically left-sided heart failure.

4. When administering an otic medication to an older adult client, which action should the nurse take to ensure that the medication reaches the inner ear?

• A. Press gently on the tragus of the client's ear
• B. Pack a small piece of cotton deep into the client's ear canal
• C. Move the client's auricle down and back toward their head
• D. Tilt the client's head backward for 5 minutes

Correct answer: A

Rationale: The correct action to ensure that otic medication reaches the inner ear is to press gently on the tragus. The tragus is a small cartilaginous projection in front of the ear canal. Pressing on it helps to straighten the ear canal, allowing the medication to reach the inner ear. Packing cotton or moving the auricle can obstruct the ear canal and prevent proper medication delivery. Tilting the client's head backward is not necessary and may not facilitate the medication reaching the inner ear as effectively as pressing on the tragus.

5. A client with a body mass index (BMI) of 30 is seeking advice on the initial approach to a weight loss plan. What action should the nurse recommend?

• A. Plan meals with low carbohydrates and high protein
• B. Engage in strenuous activity for an hour daily
• C. Keep a record of daily food and beverage intake
• D. Participate in a group exercise class three times a week

Correct answer: C

Rationale: Keeping a food diary is an essential practice when starting a weight loss plan as it helps in tracking calorie intake, identifying eating patterns, and making informed decisions about dietary changes. Planning meals with low carbohydrates and high protein (Choice A) can be beneficial for some individuals, but keeping a food diary is more foundational. Engaging in strenuous daily activity (Choice B) may not be sustainable for everyone and could lead to burnout or injuries. Participating in a group exercise class (Choice D) is beneficial for fitness but may not address dietary habits, which are crucial for weight loss.

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