Nursing Elites

1. A client with a prescription for a clear liquid diet is receiving teaching about food choices from a nurse. Which of the following selections by the client indicates an understanding of the teaching?

• A. Gelatin
• B. Whole milk
• C. Cream soups
• D. Orange juice

Correct answer: A

Rationale: The correct answer is A: Gelatin. Gelatin is suitable for a clear liquid diet because it is transparent and free of solid particles. Clear liquid diets are designed to be easily digested and leave minimal residue in the gastrointestinal tract. Choices B, C, and D are not appropriate for a clear liquid diet. Whole milk, cream soups, and orange juice contain solid particles or pulp, which are not allowed on a clear liquid diet. Whole milk and cream soups are not clear liquids as they contain milk solids and vegetable particles respectively. Orange juice contains pulp, which is not part of a clear liquid diet. It is important for clients to follow dietary restrictions to achieve the intended therapeutic outcomes.

2. A healthcare provider is providing range of motion to the shoulder and must perform external rotation. Which action will the provider take?

• A. Moves the patient's arm in a full circle.
• B. Moves the patient's arm across the body as far as possible.
• C. Moves the patient's arm behind the body, keeping the elbow straight.
• D. Moves the patient's arm until the thumb is upward and lateral to the head with the elbow flexed.

Correct answer: D

Rationale: The correct action for external rotation of the shoulder involves moving the patient's arm until the thumb is upward and lateral to the head with the elbow flexed. This position maximizes external rotation at the shoulder joint. Choices A, moving the arm in a full circle, B, moving the arm across the body, and C, moving the arm behind the body with the elbow straight, do not describe external rotation and are incorrect. Therefore, Choice D is the correct action for performing external rotation.

3. A nurse is caring for an older, immobile patient whose condition requires a supine position. Which metabolic alteration will the nurse monitor for in this patient?

• A. Increased appetite
• B. Increased diarrhea
• C. Increased metabolic rate
• D. Increased pulse rate

Correct answer: D

Rationale: When an older, immobile patient is in a supine position, it increases cardiac workload, leading to an increased pulse rate. This is because the heart rate in older adults may not tolerate the additional workload. Choices A, B, and C are incorrect because an increased appetite, increased diarrhea, and increased metabolic rate are not directly associated with being immobile in a supine position. Increased appetite is more related to nutritional needs or certain medical conditions, increased diarrhea could be due to various causes, and an increased metabolic rate is not typically a direct consequence of lying supine.

4. After abdominal surgery, a client has not urinated since the urinary catheter was removed 8 hours ago. What action should the LPN take first?

• A. Perform a bladder scan to assess for urinary retention.
• B. Encourage the client to drink fluids.
• C. Insert a straight catheter to drain the bladder.
• D. Administer a diuretic as prescribed.

Correct answer: A

Rationale: Performing a bladder scan is the initial step to assess for urinary retention in a postoperative client. This non-invasive technique helps determine the volume of urine in the bladder, guiding further interventions. Encouraging the client to drink fluids (Choice B) may be beneficial but is not the priority when assessing for urinary retention. Inserting a straight catheter (Choice C) should not be the initial action without first assessing for retention. Administering a diuretic (Choice D) should not be done without confirming the need through assessment.

5. The nurse is preparing to administer a subcutaneous injection of enoxaparin (Lovenox). Which site is most appropriate for the LPN/LVN to use?

• A. Deltoid muscle
• B. Ventrogluteal site
• C. Abdomen
• D. Dorsogluteal site

Correct answer: C

Rationale: The abdomen is the most appropriate site for administering subcutaneous injections of enoxaparin (Lovenox). Enoxaparin is typically administered in the abdomen due to better absorption and reduced risk of injury to underlying structures. The deltoid muscle is not recommended for subcutaneous injections of enoxaparin due to the potential risk of injury to underlying structures. The ventrogluteal and dorsogluteal sites are more appropriate for intramuscular injections rather than subcutaneous injections.

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