Nursing Elites

1. A 2-year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?

• A. Place the child on clear liquids and gelatin for 24 hours
• B. Continue with the regular diet and include oral rehydration fluids
• C. Give bananas, apples, rice, and toast as tolerated
• D. Place NPO for 24 hours, then rehydrate with milk and water

Correct answer: B

Rationale: In managing mild diarrhea in a 2-year-old child, it is important to maintain their regular diet and include oral rehydration fluids. Choice A of placing the child on clear liquids and gelatin for 24 hours may not provide adequate nutrition and can lead to further electrolyte imbalances. Choice C of giving bananas, apples, rice, and toast as tolerated is a part of the BRAT diet, which is not recommended as the primary approach anymore due to its limited nutritional value. Choice D of placing the child NPO for 24 hours and then rehydrating with milk and water is not appropriate as it can worsen dehydration and delay recovery. Therefore, the best option is to continue the child's regular diet while incorporating oral rehydration fluids to prevent dehydration and maintain nutritional status.

2. A post-op nurse has an indwelling catheter in place for gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse should take is to:

• A. Check to see if the tubing is kinked.
• B. Increase the IV fluid rate.
• C. Check the catheter insertion site.
• D. Contact the healthcare provider.

Correct answer: A

Rationale: The correct action for the nurse to take when the urine bag has not filled for 2 hours is to check if the tubing is kinked. Kinks in the tubing can obstruct the flow of urine from the catheter, leading to decreased drainage. Increasing the IV fluid rate is not the appropriate initial action in this situation as the primary concern is with the catheter drainage. Checking the catheter insertion site would be secondary to ensuring proper drainage. Contacting the healthcare provider is not necessary as the issue can often be resolved by checking for simple tubing obstructions first.

3. A client scheduled for a hysterectomy has not yet signed the operative consent form. When the nurse approaches the client and asks that she review and sign the form, the client says she no longer wants to have the surgery. At this time, which action should the nurse take?

• A. Ask the client why she has changed her mind
• B. Proceed with the surgery
• C. Notify the surgeon immediately
• D. Document the client’s decision

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to ask the client why she has changed her mind. By understanding the client's reasons for refusal, the nurse can address any concerns, provide further information, and ensure that the client's decision is respected. Proceeding with the surgery without clarifying the client's decision or notifying the surgeon immediately would not be appropriate. Documenting the client's decision is important, but it should be done after understanding the rationale behind the decision.

4. The healthcare provider is caring for a client with tuberculosis (TB). Which type of isolation precautions should the healthcare provider implement?

• A. Droplet precautions
• B. Airborne precautions
• C. Contact precautions
• D. Standard precautions

Correct answer: B

Rationale: When caring for a client with tuberculosis (TB), airborne precautions should be implemented. Tuberculosis is spread through the air via droplet nuclei, requiring the use of airborne precautions to prevent the transmission of the infection. Droplet precautions are used for diseases spread by large respiratory droplets, such as influenza or pertussis. Contact precautions are used for diseases that spread through direct contact, such as MRSA. Standard precautions are used for all clients to prevent the transmission of infections from blood, body fluids, non-intact skin, and mucous membranes.

5. A client with amphetamine toxicity and sensory overload is being cared for by a nurse. Which intervention should the nurse implement?

• A. Immediately conduct a thorough assessment.
• B. Encourage visitors to distract the client.
• C. Provide a private room and limit stimulation.
• D. Speak softly to the client.

Correct answer: C

Rationale: The most appropriate intervention for a client with amphetamine toxicity and sensory overload is to provide a private room and limit stimulation. This approach helps reduce external stimuli, which can exacerbate sensory overload, and creates a calming environment for the client. Encouraging visitors to distract the client may worsen sensory overload by adding more stimulation. Speaking softly, rather than at a higher volume, is more suitable to help maintain a calm environment. Therefore, the correct choice is to provide a private room and limit stimulation (option C) in this scenario.

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