Nursing Elites

1. A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following items should the nurse offer to the client?

• A. Tomato soup
• B. Apple juice
• C. Chicken broth
• D. Cranberry juice

Correct answer: C

Rationale: The correct answer is C, Chicken broth. A clear liquid diet includes clear fluids and foods that are liquid at room temperature. Chicken broth is allowed on a clear liquid diet as it is a clear liquid, while tomato soup, apple juice, and cranberry juice are not clear liquids. Tomato soup is a thicker substance and not allowed on a clear liquid diet. Apple juice and cranberry juice are also not clear liquids because they contain pulp and are not transparent like broth.

2. A nurse is caring for a client who is receiving morphine for pain management. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

• A. Diaphoresis
• B. Hypotension
• C. Urinary retention
• D. Tachycardia

Correct answer: C

Rationale: Urinary retention is an adverse effect of morphine, as it can lead to the relaxation of the detrusor muscle and sphincter constriction in the bladder. Diaphoresis, hypotension, and tachycardia are common side effects of morphine due to its vasodilatory effects and impact on the autonomic nervous system. Diaphoresis is excessive sweating, which can be a normal response to pain or fever. Hypotension and tachycardia can occur due to morphine's vasodilatory effects and its impact on the cardiovascular system. Therefore, the presence of urinary retention would indicate the need for further assessment and intervention.

3. What is the primary nursing intervention for a patient experiencing hypoglycemia?

• A. Administer IV fluids
• B. Check blood sugar levels
• C. Provide oral glucose
• D. Recheck blood sugar levels in 15 minutes

Correct answer: D

Rationale: The correct answer is to recheck blood sugar levels in 15 minutes. This intervention is crucial to ensure that the hypoglycemia has been effectively corrected after the initial treatment. Administering IV fluids may be necessary in cases of severe dehydration but is not the primary intervention for hypoglycemia. Checking blood sugar levels is important, but the primary intervention should focus on treating the low blood sugar levels first, which is done by providing oral glucose. However, the most critical step after providing initial treatment is to recheck blood sugar levels to confirm that they have improved to safe levels.

4. A nurse is planning care for a client with thrombocytopenia. Which of the following actions should the nurse include?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct answer is C: Provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing the client with a stool softener is essential to prevent straining during bowel movements, which could result in bleeding for clients with thrombocytopenia. Encouraging the client to floss daily (choice A) is unrelated to the management of thrombocytopenia. Removing fresh flowers (choice B) is more relevant for clients with a compromised immune system. Avoiding serving raw vegetables (choice D) is important for clients with compromised immune systems to prevent foodborne illnesses, but it is not directly related to thrombocytopenia.

5. A nurse is caring for a client who has a new diagnosis of deep-vein thrombosis (DVT). Which of the following actions should the nurse take?

• A. Massage the affected leg to relieve discomfort
• B. Place a heating pad on the affected leg
• C. Encourage the client to walk around frequently
• D. Monitor the client's oxygen saturation level

Correct answer: D

Rationale: The correct answer is to monitor the client's oxygen saturation level. Deep-vein thrombosis (DVT) increases the risk of pulmonary embolism, a life-threatening complication. Monitoring oxygen saturation helps in early detection of any signs of compromised respiratory function. Massaging the affected leg can dislodge a blood clot, leading to severe consequences. Applying heat through a heating pad can promote vasodilation and increase the risk of clot dislodgment. While mobility is essential in preventing DVT complications, encouraging excessive walking without proper assessment can potentially dislodge a clot and worsen the condition.

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