Nursing Elites

1. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to

• A. Call the health care provider immediately
• B. Administer acetaminophen as ordered as this is normal at this time
• C. Send blood, urine, and sputum for culture
• D. Increase the client's fluid intake

Correct answer: B

Rationale: In this scenario, the nurse should administer acetaminophen as ordered because a slight fever is normal after an MI. This intervention can help manage the fever unless other complications are present. Calling the health care provider immediately is not necessary for a slight fever post-MI. Sending blood, urine, and sputum for culture is not indicated solely based on a slight fever without other symptoms or signs of infection. Increasing fluid intake may be beneficial for various reasons but is not the priority in this situation where managing the fever with acetaminophen is appropriate.

2. A nurse is reinforcing teaching about food choice with the mother of an 8-month-old infant. Which of the following statements by the mother indicates a need for further teaching?

• A. I will give my child peanut butter and mashed egg whites.
• B. I will give my child rice cereal and crackers.
• C. I will give my child pureed liver and strained pears.
• D. I will give my child applesauce and green peas.

Correct answer: A

Rationale: The correct answer is A because peanut butter and egg whites are not recommended for infants under 12 months due to the risk of choking and allergies. Choices B, C, and D are appropriate food choices for an 8-month-old infant. Rice cereal, crackers, pureed liver, strained pears, applesauce, and green peas are all suitable options for introducing solid foods to infants.

3. A client who has chronic lymphocytic leukemia is starting chemotherapy treatments and asks if she needs to make any dietary changes. Which of the following statements by the nurse is appropriate?

• A. Use sugar-free gum if you experience a metallic taste in your mouth.
• B. Drink fluids at mealtime to prevent early satiety.
• C. Foods that are higher in fat can help nausea.
• D. Raw fruits and vegetables will be easier for your body to digest.

Correct answer: A

Rationale: The correct answer is A. Using sugar-free gum can help alleviate the metallic taste often experienced during chemotherapy treatments. Choices B, C, and D are incorrect. Drinking fluids at mealtime may worsen early satiety, foods higher in fat can exacerbate nausea, and raw fruits and vegetables may be harder for the body to digest and may pose a risk of infection for individuals with compromised immune systems.

4. A client with gastroesophageal reflux is receiving teaching from a nurse. Which statement by the client indicates a need for further teaching?

• A. I will avoid eating after supper.
• B. I can drink coffee throughout the day.
• C. I drink milk when I get heartburn.
• D. I should not eat foods made with chocolate.

Correct answer: B

Rationale: The correct answer is B. Drinking coffee throughout the day can aggravate gastroesophageal reflux symptoms. Choices A, C, and D are correct statements that can help manage gastroesophageal reflux by avoiding late-night eating, not consuming trigger foods like chocolate, and using milk for relief when experiencing heartburn.

5. A client is scheduled for a colonoscopy. Which of these instructions should the nurse provide?

• A. You should avoid eating or drinking anything after midnight the day before the test.
• B. You may have a light breakfast the morning of the test.
• C. You will need to drink a bowel preparation solution the day before the test.
• D. You will need to avoid taking any medications the day before the test.

Correct answer: C

Rationale: The correct answer is C: 'You will need to drink a bowel preparation solution the day before the test.' Before a colonoscopy, it is essential to cleanse the colon thoroughly by drinking a bowel preparation solution. This helps to ensure that the colon is clear for the procedure, allowing for better visualization and examination of the colon. Choices A, B, and D are incorrect because avoiding eating or drinking after midnight, having a light breakfast, and avoiding medications are not specific instructions related to the colonoscopy preparation process.

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