Nursing Elites

1. A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following?

• A. Sit up for at least 30 minutes after eating
• B. Avoid fluids between meals
• C. Increase the intake of high-carbohydrate foods
• D. Avoid eating large meals that are high in simple sugars and liquids

Correct answer: D

Rationale: The correct answer is D: 'Avoid eating large meals that are high in simple sugars and liquids.' Clients who have undergone partial gastrectomy are at risk of dumping syndrome, which can occur due to the rapid emptying of stomach contents into the small intestine. Consuming large meals high in simple sugars and liquids can exacerbate this syndrome, leading to symptoms like abdominal cramping and diarrhea. Choices A, B, and C are not directly related to preventing dumping syndrome and are not the priority concerns for a client post-partial gastrectomy.

2. A client has hypoglycemia and is conscious. Which of the following actions should the nurse take?

• A. Administer glucagon IM
• B. Give the client 4 oz of fruit juice
• C. Provide the client with peanut butter
• D. Give the client 1 L of water

Correct answer: B

Rationale: In conscious clients with hypoglycemia, the most appropriate action is to provide a rapidly absorbed carbohydrate source like fruit juice to raise blood glucose levels quickly. Administering glucagon intramuscularly (IM) is usually reserved for unconscious clients or those who are unable to take oral glucose. Providing peanut butter or water would not rapidly address the hypoglycemic state as fruit juice would.

3. A healthcare professional is collecting data from a client who has hypokalemia. Which of the following findings should the healthcare professional expect?

• A. Muscle stiffness
• B. Bradycardia
• C. Hyperreflexia
• D. Muscle weakness

Correct answer: D

Rationale: The correct answer is 'Muscle weakness.' Hypokalemia is characterized by low potassium levels, which can lead to muscle weakness due to impaired muscle function. Choices A, B, and C are incorrect findings associated with other medical conditions and not typically expected in hypokalemia. Muscle stiffness is more commonly associated with conditions like tetany or muscle cramps, bradycardia is more commonly associated with issues like heart block or hypothyroidism, and hyperreflexia is more commonly seen in conditions like hyperthyroidism or spinal cord injuries.

4. A client who had a vaginal delivery 4 hours ago has a fourth-degree perineal laceration. Which of the following interventions should the nurse recommend?

• A. Encourage ambulation
• B. Apply ice packs
• C. Restrict the client's fluid intake
• D. Administer stool softeners

Correct answer: B

Rationale: Correct Answer: Applying ice packs is the most appropriate intervention for a client with a fourth-degree perineal laceration. Ice packs help reduce swelling and promote comfort, aiding in the healing process. Choice A, encouraging ambulation, may not be suitable immediately after a fourth-degree laceration due to the need for rest and proper wound care. Choice C, restricting fluid intake, is not indicated and can lead to dehydration, which is not beneficial for wound healing. Choice D, administering stool softeners, may be necessary to prevent constipation and straining, but it is not the priority intervention at this time.

5. A nurse in a long-term care facility is reviewing information about health care-associated infections with a newly licensed nurse. Which of the following information should the nurse include?

• A. Frequent hand washing prevents infection
• B. Prolonged use of corticosteroids increases infection risk
• C. Limit patient interaction to reduce infection spread
• D. Restrict client movement to prevent contamination

Correct answer: B

Rationale: The correct answer is B because prolonged use of corticosteroids is a known risk factor for infections. Choice A is incorrect because frequent hand washing actually helps prevent infections. Choice C is incorrect as patient interaction is essential in healthcare but should be done following proper infection control measures. Choice D is also incorrect as restricting client movement is not a standard practice to prevent contamination.

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