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 who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?

• A. Use manual pressure to express urine
• B. Perform the Crede maneuver
• C. Apply an external urinary drainage device
• D. Take a warm sitz bath twice a day

Correct answer: B

Rationale: The correct answer is B: Perform the Crede maneuver. The Crede maneuver is a technique used to manage a flaccid bladder by applying manual pressure over the bladder area to assist in the expulsion of urine. This technique helps promote bladder emptying. Choice A is incorrect because using manual pressure to express urine is not a standardized technique and may cause harm. Choice C is incorrect as applying an external urinary drainage device does not address the need for bladder training. Choice D is unrelated to bladder training for a flaccid bladder.

3. A client admitted to the hospital for depression is escorted to a private room. Prior to leaving the room, what intervention is most important for the nurse to implement?

• A. Explain the program's guidelines
• B. Search all personal belongings
• C. Initiate psychosocial assessment
• D. Review the healthcare provider's prescription

Correct answer: B

Rationale: Searching personal belongings is essential to ensure the safety of the client by preventing access to items that could be used for self-harm. While explaining the program's guidelines (Choice A) and initiating a psychosocial assessment (Choice C) are important aspects of care, the immediate concern in this situation is the safety of the client. Reviewing the healthcare provider's prescription (Choice D) is important for providing appropriate treatment but is not as urgent as ensuring the client's safety.

4. A male client tells the nurse, 'I am so stressed because I am expected to achieve excellence in everything. My job, my marriage, and my children must be perfect!' Which coping response should the nurse recognize that the client is using?

• A. Repression
• B. Sublimation
• C. Rationalization
• D. Displacement

Correct answer: C

Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where the client justifies their stress and need for perfection by creating logical explanations or excuses. In this case, the client is rationalizing their stress by believing that everything in their life must be perfect. Repression (choice A) involves unconsciously blocking out thoughts or feelings. Sublimation (choice B) is redirecting unacceptable impulses into socially acceptable activities. Displacement (choice D) involves transferring emotions from one target to another.

5. The nurse is caring for a client who has a chest tube in place following a pneumothorax. The nurse notes that there is continuous bubbling in the water seal chamber of the chest tube drainage system. What action should the nurse take?

• A. Check for kinks in the tubing
• B. Notify the healthcare provider
• C. Replace the chest tube drainage system
• D. Reinforce the chest tube dressing

Correct answer: B

Rationale: The correct action for the nurse to take when observing continuous bubbling in the water seal chamber of the chest tube drainage system is to notify the healthcare provider. Continuous bubbling indicates a possible air leak, and the healthcare provider needs to be informed to assess the situation and take appropriate actions. Checking for kinks in the tubing (Choice A) may be done initially but is not the priority when continuous bubbling is present. Replacing the chest tube drainage system (Choice C) and reinforcing the chest tube dressing (Choice D) are not immediate actions needed in response to continuous bubbling in the water seal chamber.

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