Nursing Elites

1. What is the most important nursing action for a patient presenting with confusion after surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer IV fluids
• D. Perform a neurological assessment

Correct answer: A

Rationale: Administering oxygen is crucial for a patient presenting with confusion after surgery because it helps alleviate potential hypoxia, which can be a common cause of confusion in the postoperative period. While repositioning the patient, administering IV fluids, and performing a neurological assessment are important nursing interventions in certain situations, addressing hypoxia by administering oxygen takes priority in this case to ensure an adequate oxygen supply to the brain and other vital organs.

2. A healthcare provider is teaching a client who has a new diagnosis of hypertension about dietary management. Which of the following foods should the healthcare provider recommend?

• A. Carrots
• B. Whole grains
• C. Lean beef
• D. Bananas

Correct answer: C

Rationale: The correct answer is 'Lean beef.' Lean beef is a good source of protein, which is essential for a balanced diet. While carrots and bananas are healthy food choices, they are not specifically recommended for clients with hypertension. Whole grains are a better alternative to refined grains for individuals with hypertension, but lean beef is a more suitable recommendation due to its protein content.

3. A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of the following dietary recommendations should the nurse make?

• A. Increase your intake of high-fiber foods.
• B. Avoid foods that are high in fat.
• C. Increase your intake of dairy products.
• D. Drink carbonated beverages to help with bloating.

Correct answer: B

Rationale: The correct answer is B: "Avoid foods that are high in fat." Clients with IBS should avoid foods high in fat as they can exacerbate symptoms such as abdominal pain, bloating, and diarrhea. High-fiber foods, choice A, can sometimes worsen symptoms in individuals with IBS. Increasing intake of dairy products, choice C, may also worsen symptoms for some individuals with IBS, especially if they are lactose intolerant. Drinking carbonated beverages, choice D, can contribute to bloating and gas, making symptoms worse for individuals with IBS.

4. A nurse is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the nurse take?

• A. Heat the feeding to 105°F (40.6°C).
• B. Elevate the head of the bed to 45 degrees.
• C. Flush the tube with 0.9% sodium chloride.
• D. Verify the pH of the gastric aspirate.

Correct answer: D

Rationale: Verifying the pH of the gastric aspirate is the correct action to take before administering an intermittent enteral feeding through an NG tube. This step ensures proper tube placement in the stomach, as the gastric aspirate should have an acidic pH (usually below 5). Heating the feeding solution, elevating the head of the bed, or flushing the tube with saline are not directly related to verifying tube placement and are not the immediate actions needed before administering the feeding.

5. A client who has a new prescription for lithium is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. ''I will avoid eating foods that contain tyramine.''
• B. ''I should increase my salt intake while taking this medication.''
• C. ''I should drink at least 2 liters of water each day while taking this medication.''
• D. ''I should avoid consuming caffeinated beverages while taking this medication.''

Correct answer: C

Rationale: The correct answer is C. Drinking at least 2 liters of water daily is crucial for clients taking lithium to prevent dehydration and lithium toxicity. Lithium is a salt, so it's important for clients to maintain adequate hydration. Option A is incorrect because lithium does not interact with tyramine-containing foods. Option B is incorrect because increasing salt intake is not necessary and can actually exacerbate lithium toxicity. Option D is incorrect because avoiding caffeinated beverages is not a priority teaching point for clients taking lithium.

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