Nursing Elites

1. A nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?

• A. cold, burning, aching, and numbness
• B. burning, aching, cold, and numbness
• C. aching, cold, burning, and numbness
• D. cold, aching, burning, and numbness

Correct answer: A

Rationale: The correct order of sensations experienced with an ice water bath is cold, burning, aching, and numbness, as stated by the acronym CBAN (cold, burn, ache, numbness). Option A is the correct sequence. Choice B is incorrect as it starts with burning, which typically follows the cold sensation. Choice C is incorrect as aching is usually felt after the burning sensation. Choice D is incorrect as aching usually occurs after the burning sensation.

2. A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to:

• A. Remove air from the pleural space
• B. Create access for irrigating the chest cavity
• C. Evacuate secretions from the bronchioles and alveoli
• D. Drain blood and fluid from the pleural space

Correct answer: A

Rationale: The correct answer is 'Remove air from the pleural space.' When a client has two chest tubes in place post-thoracotomy, the upper chest tube is typically positioned to remove air from the pleural space. Air rises, so placing the tube at the top allows for efficient removal of air that has accumulated in the pleural cavity. Choice B, creating access for irrigating the chest cavity, is incorrect as chest tubes are not primarily used for irrigation. Choice C, evacuating secretions from the bronchioles and alveoli, is incorrect as chest tubes are not designed for this purpose. Choice D, draining blood and fluid from the pleural space, is also incorrect as the upper chest tube in this scenario is specifically for removing air, not blood or fluid.

3. How can a diet high in fiber content benefit an individual?

• A. aid in rapid weight loss.
• B. reduce diabetic ketoacidosis.
• C. lower cholesterol.
• D. reduce the requirement for folate.

Correct answer: C

Rationale: A diet high in fiber content can help lower cholesterol levels. Fiber-rich foods such as grains, apples, potatoes, and beans are known to aid in reducing cholesterol by binding to cholesterol in the digestive system and preventing its absorption into the bloodstream. Choice A is incorrect as the question does not specify losing weight rapidly but rather focuses on the benefits of a high-fiber diet, which includes aiding in weight management through promoting satiety and regulating digestion. Choice B is incorrect because while fiber helps manage blood sugar levels, it is not directly related to reducing diabetic ketoacidosis, a serious complication of diabetes. Choice D is incorrect as a high-fiber diet does not reduce the need for folate; however, it can aid in the absorption of folate and other essential nutrients.

4. Which of the following statements should the nurse use to best describe a very low-calorie diet (VLCD) to a client?

• A. "This diet can be used when there is close medical supervision."?
• B. "This is a long-term treatment measure that assists obese people who can't lose weight."?
• C. "The VLCD consists of solid food items that are pureed to facilitate digestion and absorption."?
• D. "A VLCD contains very little protein."?

Correct answer: A

Rationale: The correct answer is, "This diet can be used when there is close medical supervision."? Very low-calorie diets (VLCDs) are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality protein, and has a minimum of carbohydrates to spare protein and prevent ketosis. Choice B is incorrect because VLCDs are typically short-term interventions. Choice C is incorrect because VLCDs usually consist of nutritionally complete liquid formulations, not solid food items that are pureed. Choice D is incorrect because VLCDs actually contain a high quality of protein, although the overall caloric content is very low.

5. If your patient is acutely psychotic, which of the following independent nursing interventions would not be appropriate?

• A. Conveying calmness through one-on-one interaction
• B. Recognizing and managing your own feelings to prevent escalation of the patient's anxiety level
• C. Encouraging client participation in group therapy
• D. Listening and identifying causes of their behavior

Correct answer: C

Rationale: When a patient is acutely psychotic, they may not be able to effectively participate in group therapy due to their altered mental state. Group settings can be overwhelming and may exacerbate the patient's symptoms. Choices A, B, and D are appropriate interventions. Choice A is correct as providing calmness through one-on-one interaction can be beneficial in establishing trust and reducing anxiety. Choice B is also important as recognizing and managing the nurse's feelings can prevent further escalation of the patient's symptoms. Choice D is relevant as listening and identifying causes of the patient's behavior can aid in understanding and providing appropriate care tailored to the patient's needs.

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