Nursing Elites

1. A client receiving filgrastim (Neupogen) for neutropenia is learning about compromised host precautions. The selection of which lunch suggests the client has learned about necessary dietary changes?

• A. grilled chicken sandwich and skim milk
• B. roast beef, mashed potatoes, and green beans
• C. peanut butter sandwich, banana, and iced tea
• D. barbecue beef, baked beans, and cole slaw

Correct answer: B

Rationale: Roast beef, mashed potatoes, and green beans are suitable choices for clients with neutropenia because they are considered safe options that help avoid potential sources of infection. Grilled chicken, peanut butter, and barbecue beef may carry a higher risk of bacterial contamination, which could be harmful to a client with compromised immunity.

2. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?

• A. Clamp the chest tube
• B. Call the surgeon immediately
• C. Prepare for blood transfusion
• D. Continue to monitor the rate of drainage

Correct answer: D

Rationale: In this scenario, the most appropriate nursing action is to continue to monitor the rate of drainage. Clamping the chest tube is not recommended as it can lead to a tension pneumothorax. Calling the surgeon immediately may not be necessary at this point unless the drainage rate significantly increases or other concerning symptoms develop. Preparing for a blood transfusion is premature without further assessment and monitoring of the client's condition. Monitoring the rate of drainage allows the nurse to assess for any potential complications and ensure that the drainage amount is within expected limits.

3. A client with diabetes is being educated about the dietary source that should provide the greatest percentage of their calories. Which of the following statements by the client indicates an understanding of the teaching?

• A. Most of my calories each day should be from fats.
• B. I should eat more calories from complex carbohydrates than anything else.
• C. Simple sugars are needed more than other calorie sources.
• D. Protein should be my main source of calories.

Correct answer: B

Rationale: The correct answer is B. In diabetes management, complex carbohydrates should constitute the largest portion of the diet as they help in maintaining steady energy levels and managing blood sugar. Choice A is incorrect because a high-fat diet can lead to complications in diabetes. Choice C is incorrect as simple sugars can cause rapid spikes in blood sugar levels. Choice D is incorrect as protein, while important, should not be the main source of calories for a diabetic individual.

4. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is

• A. Abdominal x-ray
• B. Auscultation
• C. Flushing tube with saline
• D. Aspiration for gastric contents

Correct answer: D

Rationale: After the insertion of an enteral feeding tube, the most accurate method for verifying its placement is by aspirating gastric contents. This method ensures that the tube is correctly positioned in the stomach. Abdominal x-ray can provide additional confirmation but is not as immediate or practical. Auscultation and flushing the tube with saline are not as reliable as aspirating gastric contents for verifying proper placement of an enteral feeding tube.

5. A nurse at a provider's office is reinforcing teaching with a client who is being treated with chemotherapy and is losing weight. Which of the following instructions should the nurse give to increase the client's caloric intake? (Select one that doesn't apply).

• A. Top yogurt with granola.
• B. Use honey on toast.
• C. Use milk instead of water in recipes.
• D. Increase fluids during meals.

Correct answer: D

Rationale: Increasing fluids during meals does not directly contribute to increasing caloric intake. Topping yogurt with granola, using honey on toast, and using milk instead of water in recipes are effective ways to boost caloric intake. While adequate fluid intake is important for hydration and overall health, it does not address the specific need to increase caloric intake in this scenario.

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