Nursing Elites

1. A client receiving chemotherapy has severe neutropenia. What snack is best for the nurse to recommend?

• A. Baked apples with raisins.
• B. Yogurt with fresh berries.
• C. Avocados and cheese.
• D. Fresh fruit salad.

Correct answer: B

Rationale: For a client with severe neutropenia, it is crucial to recommend a snack that is low in bacteria to reduce the risk of infection. Yogurt with fresh berries is an excellent choice as it is not only low in bacteria but also provides nutritional value. Baked apples with raisins (choice A) may not be ideal as the preparation process could introduce bacteria. Avocados and cheese (choice C) may not be the best option due to their potential bacterial content. Fresh fruit salad (choice D) may have a higher risk of bacterial contamination compared to yogurt with fresh berries.

2. An older adult client with gastroenteritis has been taking the antidiarrheal diphenoxylate for the past 24 hours. What finding requires the nurse to take further action?

• A. Monitor the client’s fluid intake.
• B. Obtain a stool sample for testing.
• C. Administer a laxative to clear the infection.
• D. Assess skin turgor and provide fluids.

Correct answer: D

Rationale: The correct answer is D. Assessing skin turgor is crucial as tented skin turgor indicates dehydration, which can be worsened by antidiarrheal medications like diphenoxylate. Providing fluids is essential to address dehydration in this client. Monitoring fluid intake (choice A) is important, but assessing skin turgor takes precedence in this situation. Obtaining a stool sample for testing (choice B) could be necessary for diagnostic purposes but is not the immediate priority. Administering a laxative (choice C) is contraindicated in this case as it can worsen the client's condition by further exacerbating fluid loss.

3. A client is admitted with pneumonia and is started on antibiotics. After 3 days, the client reports difficulty breathing and a rash. What is the nurse's first action?

• A. Administer epinephrine
• B. Discontinue the antibiotic
• C. Assess the client's oxygen saturation
• D. Call the healthcare provider

Correct answer: B

Rationale: The client's difficulty breathing and rash suggest a possible allergic reaction to the antibiotic. The first action the nurse should take is to discontinue the antibiotic to prevent further exposure. Administering epinephrine should only be done in severe cases of anaphylaxis, which is not indicated solely by difficulty breathing and rash. While assessing the client's oxygen saturation is important, discontinuing the potential allergen takes precedence. Contacting the healthcare provider should be done after discontinuing the antibiotic and assessing the client to report the situation and seek further guidance.

4. When a pediatric client is taking the beta-adrenergic blocking agent propranolol, what signs of overdose should the nurse instruct the parents to report?

• A. Seizures
• B. Increased respiratory rate
• C. Bradycardia
• D. Irritability

Correct answer: C

Rationale: When a pediatric client is taking propranolol, the nurse should instruct the parents to report signs of overdose, including bradycardia. Propranolol is a beta-blocker that can lead to dangerously slow heart rate as a sign of overdose. While increased respiratory rate, seizures, and irritability may occur in some cases, bradycardia is the most critical symptom indicating an overdose of this medication.

5. A young male client is admitted to rehabilitation following a right AKA (above-the-knee amputation) for a severe traumatic injury. He is in the commons room and anxiously calls out to the nurse, stating that his 'right foot is aching.' The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement?

• A. Teach the client distraction techniques
• B. Provide a soft blanket to ease discomfort
• C. Administer prescribed pain medication
• D. Encourage discussion of feelings about the loss of his limb

Correct answer: D

Rationale: The client's report of pain in a missing limb is consistent with phantom limb pain, which can be distressing. Encouraging the client to discuss his feelings helps address the emotional and psychological aspects of the amputation and supports his overall recovery. Teaching distraction techniques (choice A) may provide temporary relief but does not address the underlying emotional distress. Providing a soft blanket (choice B) is not the priority when dealing with phantom limb pain. Administering pain medication (choice C) may not effectively manage phantom limb pain as it is more related to central nervous system changes rather than tissue damage.

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