Nursing Elites

1. A 4-year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?

• A. Notify the healthcare provider
• B. Readjust the traction
• C. Administer the ordered PRN medication
• D. Reassess the foot in fifteen minutes

Correct answer: A

Rationale: In this situation, a pale foot with the absence of a pulse indicates compromised circulation, which is a critical emergency. The nurse should immediately notify the healthcare provider to address the circulation issue promptly. Reading the question and understanding the urgency is vital. Readjusting the traction, administering PRN medication, or waiting to reassess the foot in fifteen minutes are not appropriate actions when a child is experiencing compromised circulation.

2. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

• A. Add a thickening agent to the fluids
• B. Check the client's gag reflex
• C. Feed the client only solid foods
• D. Increase the rate of intravenous fluids

Correct answer: B

Rationale: Checking the client's gag reflex is the appropriate action in this scenario. It helps assess the client's ability to swallow safely without the risk of aspiration. Adding a thickening agent to the fluids (Choice A) may be considered later if swallowing difficulties persist. Feeding the client only solid foods (Choice C) can increase the risk of aspiration in this case, and increasing the rate of intravenous fluids (Choice D) does not address the swallowing concern.

3. A nurse is reinforcing teaching with a group of older adults about oil-rich foods. The nurse should include which of the following foods as the equivalent of 4 tsp of oil?

• A. 1 tbsp of soft margarine
• B. ½ oz of nuts
• C. 2 tbsp of peanut butter
• D. 1 oz of sunflower seeds

Correct answer: C

Rationale: The correct answer is C: 2 tbsp of peanut butter. Two tablespoons of peanut butter is approximately equivalent to 4 teaspoons of oil, providing healthy fats in the diet. Choice A, 1 tbsp of soft margarine, is not equivalent to 4 tsp of oil as margarine contains additional ingredients. Choice B, ½ oz of nuts, and choice D, 1 oz of sunflower seeds, do not provide an equivalent amount of oil as requested in the question.

4. A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?

• A. Have him drink several glasses of water
• B. Crede the bladder from the bottom to the top
• C. Assist him to stand by the side of the bed to void
• D. Wait 2 hours and have him try to void again

Correct answer: C

Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action. This position can help stimulate voiding due to gravity and normal positioning. Having the client drink water (Choice A) may help, but assisting him to stand is more effective. Crede maneuver (Choice B) is not recommended as it can increase the risk of bladder trauma. Waiting for 2 hours (Choice D) without taking any action is not proactive in addressing the client's inability to void.

5. A client receiving filgrastim (Neupogen) for neutropenia is learning about compromised host precautions. The selection of which lunch suggests the client has learned about necessary dietary changes?

• A. grilled chicken sandwich and skim milk
• B. roast beef, mashed potatoes, and green beans
• C. peanut butter sandwich, banana, and iced tea
• D. barbecue beef, baked beans, and cole slaw

Correct answer: B

Rationale: Roast beef, mashed potatoes, and green beans are suitable choices for clients with neutropenia because they are considered safe options that help avoid potential sources of infection. Grilled chicken, peanut butter, and barbecue beef may carry a higher risk of bacterial contamination, which could be harmful to a client with compromised immunity.

Similar Questions