Nursing Elites

1. A child with Leukemia is admitted for chemotherapy, and the nursing diagnosis, altered nutrition, less than body requirements related to anorexia, nausea, vomiting is identified. Which intervention should the nurse include in this child's plan of care?

• A. Allow the child to eat foods desired and tolerated
• B. Restrict foods brought from fast food restaurants
• C. Recommend eating the same foods as siblings eat at home
• D. Encourage a variety of large portions of food at every meal

Correct answer: A

Rationale: The correct intervention for a child with Leukemia undergoing chemotherapy and experiencing altered nutrition, less than body requirements due to anorexia, nausea, and vomiting is to allow the child to eat foods desired and tolerated. This intervention helps improve the child's nutrition intake during chemotherapy. Choice B is incorrect because restricting foods may further limit the child's nutritional intake. Choice C is incorrect because recommending eating the same foods as siblings may not align with the child's preferences or needs during treatment. Choice D is incorrect as encouraging large portions of food at every meal may overwhelm the child and be counterproductive to their nutritional needs.

2. A client with chronic renal failure is receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input and that the client's abdomen is distended. What action should the nurse take first?

• A. Turn the client from side to side
• B. Increase the dwell time of the dialysis
• C. Reposition the client
• D. Milk the catheter

Correct answer: A

Rationale: The correct first action for the nurse to take is turning the client from side to side. This helps to facilitate drainage in peritoneal dialysis. Turning the client can aid in redistributing the dialysate and promoting better drainage. Increasing the dwell time of the dialysis (choice B) may not address the immediate issue of inadequate drainage. Repositioning the client (choice C) might not be as effective as turning the client from side to side. Milking the catheter (choice D) is not recommended as it can lead to complications. In this situation, the priority is to facilitate drainage to address the distended abdomen.

3. What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis?

• A. Avoid douching
• B. Treat sexual partner(s) concurrently
• C. Avoid using moist washcloths when bathing
• D. Postpone becoming pregnant until the infection is treated

Correct answer: B

Rationale: The most important instruction for a female client diagnosed with trichomoniasis is to treat sexual partner(s) concurrently. This is crucial to prevent reinfection and the spread of the infection. Choice A, avoiding douching, is generally recommended for vaginal health but is not the most critical instruction in this case. Choice C, avoiding moist washcloths when bathing, is not directly related to the transmission or treatment of trichomoniasis. Choice D, postponing pregnancy until the infection is treated, is important but treating sexual partners concurrently takes precedence to prevent reinfection.

4. The nurse is caring for a client with a diagnosis of pneumonia who has been febrile for 24 hours. Which data is most important for the nurse to obtain in determining the client's fluid status?

• A. Daily intake and output
• B. Skin turgor
• C. Daily weight
• D. Vital signs every 4 hours

Correct answer: C

Rationale: Daily weight is the most important data for the nurse to obtain in determining the client's fluid status in this scenario. During febrile episodes, assessing daily weight is crucial as it can indicate fluid retention or loss. While monitoring intake and output is important for assessing fluid balance, daily weight provides a more comprehensive picture of fluid status over time. Skin turgor is more indicative of hydration status than overall fluid status, and vital signs, although essential, do not directly assess fluid status as effectively as daily weight.

5. The nurse is caring for a client who is 2 days post-op following an abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?

• A. Apply a sterile saline dressing to the wound
• B. Notify the healthcare provider
• C. Administer pain medication
• D. Cover the wound with an abdominal binder

Correct answer: A

Rationale: In this situation, the priority action for the nurse is to apply a sterile saline dressing to the wound. This helps prevent infection and keeps the wound moist, which is crucial in promoting healing and preventing further complications. Option B, notifying the healthcare provider, is important but should come after addressing the wound. Administering pain medication (Option C) may be necessary but is not the first action to take in this emergency situation. Covering the wound with an abdominal binder (Option D) is not appropriate and may cause further harm by applying pressure to the protruding bowel.

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