Nursing Elites

1. A nurse is reinforcing teaching about a clear liquid diet. What should the client avoid?

• A. Lemon-lime sports drinks
• B. Orange sherbet
• C. Black coffee
• D. Ginger ale

Correct answer: D

Rationale: The correct answer is D, Ginger ale. A clear liquid diet includes fluids that are see-through and easily digestible. Ginger ale is a carbonated beverage that is allowed on a clear liquid diet. Orange sherbet, choice B, is not suitable for a clear liquid diet as it contains dairy products and solid particles, which are not transparent. Lemon-lime sports drinks, choice A, may contain added colorings or particles that are not allowed on a clear liquid diet. Black coffee, choice C, is also not recommended on a clear liquid diet as it is not a clear liquid and contains substances that may be hard to digest.

2. A nurse is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation?

• A. Pupils constrict when shifting gaze from near to far
• B. Pupils constrict when shifting gaze from far to near
• C. Lack of change in pupil size when shifting gaze from near to far
• D. Lack of change in pupil size when shifting gaze from far to near

Correct answer: D

Rationale: Pupil accommodation problems are indicated by the lack of change in size when shifting gaze from far to near. The correct answer is D because in pupil accommodation, the pupils should constrict when shifting gaze from far to near in order to adjust for near vision. Choices A and B describe normal responses of pupil constriction when shifting gaze, which do not indicate a problem. Choice C is incorrect as it describes a normal response of pupil size change when shifting gaze from near to far.

3. A client has developed phlebitis at the IV site. What is the next step the nurse should take?

• A. Administer an anti-inflammatory medication
• B. Discontinue the IV and notify the provider
• C. Apply a cold compress over the IV site
• D. Increase the IV flow rate to prevent dehydration

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the nurse's immediate action should be to discontinue the IV and notify the healthcare provider. Phlebitis is inflammation of the vein, and leaving the IV in place can lead to complications such as infection or thrombosis. Administering an anti-inflammatory medication (choice A) may not address the root cause and delay the necessary intervention. Applying a cold compress (choice C) may provide temporary relief but does not address the need to remove the source of inflammation. Increasing the IV flow rate (choice D) is contraindicated as it can exacerbate the phlebitis by causing more irritation to the vein.

4. A client with a tracheostomy is exhibiting signs of respiratory distress. What should the nurse do first?

• A. Notify the healthcare provider
• B. Suction the tracheostomy
• C. Administer a bronchodilator
• D. Increase the oxygen flow rate

Correct answer: B

Rationale: When a client with a tracheostomy is experiencing respiratory distress, the priority action is to suction the tracheostomy to clear the airway and improve breathing. This helps remove secretions or blockages that may be causing the distress. Notifying the healthcare provider (Choice A) can be done after ensuring immediate airway clearance. Administering a bronchodilator (Choice C) would not address the primary issue of airway clearance in a tracheostomy patient. Increasing the oxygen flow rate (Choice D) may be necessary but should come after ensuring the airway is clear.

5. A home health nurse is caring for an older adult client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?

• A. Assess mobility
• B. Monitor vital signs
• C. Provide pain relief
• D. Reinforce discharge teaching

Correct answer: A

Rationale: Assessing mobility should be the nurse's priority as it ensures the client's safety and helps in developing an appropriate care plan. By evaluating the client's ability to move after the knee arthroplasty, the nurse can identify any immediate issues or complications that need to be addressed promptly. Monitoring vital signs, providing pain relief, and reinforcing discharge teaching are important aspects of care but assessing mobility takes precedence in ensuring the client's immediate well-being and identifying any potential risks.

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