Nursing Elites

1. The client has recently been diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?

• A. Instruct the client to avoid drinking fluids with meals
• B. Explain the need to decrease intake of flatus-forming foods
• C. Teach the client how to perform gentle perianal care
• D. Encourage the client to see a psychologist

Correct answer: B

Rationale: The correct answer is B. Decreasing the intake of flatus-forming foods can help reduce symptoms of bloating and discomfort in IBS. This intervention focuses on dietary modifications that can positively impact the client's condition. Instructing the client to avoid drinking fluids with meals (choice A) may not directly address the underlying cause of IBS symptoms. Teaching perianal care (choice C) is important for hygiene but does not directly address IBS symptoms. Encouraging the client to see a psychologist (choice D) may be beneficial for managing stress or anxiety associated with IBS but does not directly target symptom reduction through dietary changes.

2. The client with peripheral venous disease is scheduled to go to the whirlpool for a dressing change. Which is the nurse’s priority intervention?

• A. Escort the client to the physical therapy department
• B. Medicate the client 30 minutes before going to the whirlpool
• C. Obtain the sterile dressing supplies for the client
• D. Assist the client to the bathroom prior to the treatment

Correct answer: B

Rationale: The correct answer is B. Pain management is essential before the procedure to ensure the client’s comfort and cooperation during the dressing change. Escorting the client to the physical therapy department (choice A) is not the priority at this time. While obtaining sterile dressing supplies (choice C) is important, ensuring pain management takes precedence. Assisting the client to the bathroom (choice D) is not directly related to the priority intervention of pain management before the whirlpool treatment.

3. Which nutrient deficiency is most likely to be seen in patients with chronic alcoholism?

• A. Vitamin C
• B. Vitamin D
• C. Vitamin B12
• D. Vitamin B1

Correct answer: D

Rationale: Patients with chronic alcoholism are most likely to develop a deficiency in Vitamin B1 (thiamine) due to poor dietary intake and impaired absorption. This deficiency can lead to conditions like Wernicke's encephalopathy and Korsakoff's syndrome. While deficiencies in other vitamins can also occur in chronic alcoholism, Vitamin B1 deficiency is more commonly associated with this condition, making it the most likely nutrient deficiency in these patients. Therefore, the correct answer is Vitamin B1 (Choice D). Deficiencies in Vitamin C (Choice A), Vitamin D (Choice B), and Vitamin B12 (Choice C) can also be seen in patients with chronic alcoholism, but they are not as commonly linked to this condition compared to Vitamin B1 deficiency.

4. Clinitest is used in testing the urine of a client for glucose. Which of the following, if committed by a nurse, indicates an error?

• A. Specimen is collected after meals
• B. The nurse puts the clingiest tablet into a test tube
• C. She added 5 drops of urine and 10 drops of water
• D. If the color becomes orange or red, It is considered

Correct answer: C

Rationale: When conducting a Clinitest for testing urinary glucose levels, it is essential to add the correct amounts of urine and Clinitest reagent as instructed. Adding more water than urine could dilute the sample, leading to inaccurate test results. It's important to follow the correct ratio of drops specified in the instructions for an accurate reading.

5. For which client situation would a consultation with a rapid response team (RRT) be most appropriate?

• A. 45-year-old; 2 years post kidney transplant; second hospital day for treatment of pneumonia; no urine output for 6 hours; temperature 101.4°F; heart rate of 98 beats per minute; respirations 20 breaths per minute; blood pressure 88/72 mm Hg; is restless
• B. 72-year-old; 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion); temperature 97.8°F; heart rate 92 beats per minute; respirations 28 breaths per minute; blood pressure 132/86 mm Hg; anxious about going home
• C. 56-year-old fourth hospital day after a coronary artery bypass procedure; sore chest; pain with walking temperature 97°F; heart rate 84 beats per minute; respirations 22 breaths per minute; blood pressure 87/72 mm Hg; bored with hospitalization.
• D. 86-year-old; 48 hours postoperative repair of a fractured hip (nail inserted; alert; oriented; using patient-controlled analgesia (PCA) pump; temperature 96.8°F; heart rate 60 beats per minute; respirations 16 breaths per minute; blood pressure 90/62 mm Hg; talking with daughter.

Correct answer: A

Rationale: A consultation with a Rapid Response Team (RRT) is most appropriate for the 45-year-old client described in Choice A. This client is 2 years post kidney transplant, presenting with no urine output for 6 hours, a temperature of 101.4°F, heart rate of 98 beats per minute, respirations of 20 breaths per minute, and a blood pressure of 88/72 mm Hg, along with restlessness. These clinical signs are indicative of possible acute renal failure and sepsis, requiring immediate intervention by the rapid response team. Choices B, C, and D do not present the same level of urgency and severity of symptoms as the client in Choice A, making them less appropriate for consultation with the RRT.

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