Nursing Elites

1. The nurse offers diet teaching to a female college student who was diagnosed with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet?

• A. Drink whole milk instead of skim milk to enhance the body's production of amino acids
• B. Take vitamin K 10mg PO daily to enhance production of red blood cells
• C. Increase amounts of dark yellow vegetables such as carrots to fortify iron stores
• D. Combine several legumes and grains such as beans and rice to form complete proteins

Correct answer: D

Rationale: Combining legumes and grains ensures the client receives all essential amino acids to form complete proteins, which is crucial in a vegetarian diet. Options A, B, and C are incorrect. Option A is not necessary as there are plant-based sources of essential amino acids in a lacto-vegetarian diet. Option B suggests vitamin K, which is not directly related to enhancing red blood cell production. Option C mentions increasing dark yellow vegetables, which are sources of non-heme iron, but combining legumes and grains is more effective in addressing the protein needs of a lacto-vegetarian.

2. A client in acute renal failure has a serum potassium of 7.5 mEq/L. Based on this finding, the nurse should anticipate implementing which action?

• A. Administer an IV of normal saline rapidly and NPH insulin subcutaneously.
• B. Administer a retention enema of Kayexalate.
• C. Add 40 mEq of KCL (potassium chloride) to the present IV solution.
• D. Administer a lidocaine bolus IV push.

Correct answer: B

Rationale: In acute renal failure with a high serum potassium level, the priority intervention is to lower potassium levels to prevent complications like cardiac arrhythmias. Administering a retention enema of Kayexalate is the correct action as it helps lower high potassium levels by exchanging sodium for potassium in the intestines. Options A, C, and D are incorrect. Administering normal saline rapidly and NPH insulin or adding more potassium to the IV solution can further increase potassium levels, worsening the condition. Lidocaine is not indicated for treating hyperkalemia.

3. In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?

• A. Measure the client's oxygen saturation before taking further action
• B. Administer a PRN dose of nitroglycerin (Nitrostat)
• C. Administer the dose of furosemide as scheduled
• D. Hold the dose of furosemide until contacting the healthcare provider

Correct answer: C

Rationale: Administering the scheduled dose of furosemide is appropriate when a client with heart failure has an elevated BNP level. BNP elevation indicates fluid overload, and furosemide is a diuretic that helps in reducing excess fluid. Measuring the client's oxygen saturation (Choice A) is not directly related to addressing fluid overload. Administering nitroglycerin (Choice B) is not indicated for managing elevated BNP levels. Holding the furosemide dose (Choice D) would delay appropriate treatment for fluid overload.

4. A male client admitted three days ago with respiratory failure is intubated, and 40% oxygen per facemask is initiated. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?

• A. Exhibits adequate tissue perfusion
• B. Remains free of injury
• C. Remains free of infection
• D. Maintains effective breathing pattern

Correct answer: D

Rationale: Successful extubation relies on the patient's ability to maintain an effective breathing pattern. This indicates that the patient can adequately oxygenate and ventilate without the need for mechanical support. Monitoring tissue perfusion, preventing infection, and ensuring safety are important but not directly related to the immediate criteria for successful extubation. Tissue perfusion, injury prevention, and infection control are crucial aspects of overall patient care but are not the primary factors to consider when evaluating readiness for extubation.

5. A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?

• A. The depth of tissue destruction is minor
• B. Pain is interrupted due to nerve compression
• C. The full thickness burn has destroyed the nerves
• D. Second-degree burns are not usually painful

Correct answer: C

Rationale: The correct answer is C: 'The full thickness burn has destroyed the nerves.' In full thickness burns, also known as third-degree burns, the nerve endings are destroyed, leading to a lack of pain sensation at the site of the burn. The description of the burn as dry, waxy, and white indicates a full thickness burn. Choices A, B, and D are incorrect because they do not explain the absence of pain in full thickness burns. Choice A is incorrect as a full-thickness burn involves significant tissue destruction. Choice B is incorrect because nerve compression would not explain the lack of pain in this context. Choice D is incorrect because second-degree burns, unlike full-thickness burns, are painful due to nerve endings being intact.

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