Nursing Elites

1. A nurse is reviewing the medical record of a client who is receiving gentamicin for a wound infection. Which of the following findings should the nurse report to the provider?

• A. Blood urea nitrogen (BUN) 25 mg/dL
• B. Serum creatinine 1.5 mg/dL
• C. Serum glucose 110 mg/dL
• D. White blood cell (WBC) count 5,000/mm3

Correct answer: A

Rationale: An elevated BUN level indicates possible nephrotoxicity, which is a side effect of gentamicin and should be reported. Elevated serum creatinine and WBC count are not specifically related to gentamicin therapy. Normal serum glucose levels are also within the expected range.

2. A nurse is caring for a client who is postoperative following a cholecystectomy. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 110/70 mm Hg
• B. Temperature of 37.2°C (99°F)
• C. Serosanguineous wound drainage
• D. Bile-colored drainage from the surgical site

Correct answer: D

Rationale: Bile-colored drainage from the surgical site can indicate a bile leak, which is an abnormal finding and should be reported. A blood pressure of 110/70 mm Hg and a temperature of 37.2°C (99°F) are within normal ranges for a postoperative client. Serosanguineous wound drainage, which is a mix of blood and serum, is expected following a surgery like cholecystectomy. Therefore, choices A, B, and C are not findings that require immediate reporting.

3. A nurse is providing dietary teaching to a client who has a new diagnosis of celiac disease. Which of the following foods should the nurse instruct the client to avoid?

• A. Rice
• B. Barley soup
• C. Cornbread
• D. Potatoes

Correct answer: B

Rationale: The correct answer is B: Barley soup. Barley contains gluten, which is harmful to individuals with celiac disease. Therefore, the nurse should instruct the client to avoid barley-containing foods like barley soup. Choices A, C, and D are safe options for individuals with celiac disease as they do not contain gluten. Rice, cornbread, and potatoes are gluten-free and can be included in the client's diet.

4. A nurse is preparing a sterile field for a client with a surgical wound. Which of the following actions should the nurse take to maintain the sterile field?

• A. Open sterile packages using the flap closest to your body first.
• B. Don sterile gloves before opening the sterile package.
• C. Avoid reaching over the sterile field.
• D. Place sterile items at least 2.5 cm (1 in) from the edge of the sterile field.

Correct answer: C

Rationale: The correct action to maintain a sterile field is to avoid reaching over it. This prevents contamination of the sterile environment by reducing the risk of unintentionally dropping microorganisms from non-sterile areas onto the sterile field. Opening sterile packages using the flap closest to your body first (choice A) is a good practice but not directly related to maintaining the sterile field. Donning sterile gloves before opening the sterile package (choice B) is crucial for maintaining sterility but not specific to maintaining the sterile field. Placing sterile items at least 2.5 cm (1 in) from the edge of the sterile field (choice D) is important to prevent accidental contamination, but it is not the primary action to maintain the sterile field.

5. A nurse is providing discharge teaching to a client with type 2 diabetes mellitus. Which of the following resources should the nurse provide?

• A. Personal blogs about managing diabetes medications.
• B. Food label recommendations from the Institute of Medicine.
• C. Diabetes medication information from the Physicians' Desk Reference.
• D. Food exchange lists for meal planning from the American Diabetes Association.

Correct answer: D

Rationale: The correct answer is D. Food exchange lists are valuable resources for individuals with diabetes as they provide structured meal planning guidance. This helps individuals manage their diabetes effectively by controlling their carbohydrate intake. Choices A, B, and C are incorrect because personal blogs may not provide reliable and evidence-based information, food label recommendations from the Institute of Medicine may not be specific for diabetes meal planning, and diabetes medication information from the Physicians' Desk Reference is not directly related to meal planning for diabetes management.

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