Nursing Elites

1. The nurse is teaching the client diagnosed with Type 2 diabetes mellitus about diet. Which diet selection indicates the client understands the teaching?

• A. A submarine sandwich, potato chips, and diet cola
• B. Four (4) slices of a supreme thin-crust pizza and milk
• C. Smoked turkey sandwich, celery sticks, and unsweetened tea
• D. A roast beef sandwich, fried onion rings, and a cola

Correct answer: C

Rationale: The correct answer is C because a smoked turkey sandwich with celery sticks and unsweetened tea is a healthier option for someone with Type 2 diabetes mellitus. Turkey is a lean protein source, celery sticks are low in calories and carbs, and unsweetened tea is a better choice than sugary beverages. Choices A, B, and D are incorrect. Choice A includes high-carb and high-sugar items like potato chips and diet cola, which are not ideal for diabetes management. Choice B contains a high-carb pizza and milk, which may not be suitable for controlling blood sugar levels. Choice D includes fried onion rings and cola, which are high in unhealthy fats and sugars, making it a poor choice for a diabetic diet.

2. The nurse is caring for a client recovering from intestinal surgery. Which assessment finding would require immediate intervention?

• A. Presence of thin pink drainage in the Jackson Pratt drain
• B. Guarding when the nurse touches the abdomen
• C. Tenderness around the surgical site during palpation
• D. Complaints of chills and feeling feverish

Correct answer: D

Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. In this postoperative setting, the presence of thin pink drainage in the Jackson Pratt drain is expected as part of the normal healing process. Guarding when the nurse touches the abdomen and tenderness around the surgical site are common after surgery and may not require immediate intervention unless they are severe or accompanied by other concerning symptoms.

3. The nurse understands that which are characteristics of anthrax? Select all that apply.

• A. Cutaneous lesions become a black eschar, Flu-like symptoms are a sign of pulmonary anthrax
• B. Cutaneous lesions become a black eschar
• C. Gastrointestinal anthrax causes blood anthrax
• D. Flu-like symptoms are a sign of pulmonary anthrax

Correct answer: A

Rationale: The correct characteristics of anthrax are that cutaneous lesions become a black eschar, and flu-like symptoms are typical of pulmonary anthrax. Choice B is incorrect as it only covers the cutaneous anthrax characteristic and does not include the flu-like symptoms of pulmonary anthrax. Choice C is incorrect as gastrointestinal anthrax does not cause 'blood anthrax,' and Choice D is incorrect as flu-like symptoms are not associated with gastrointestinal anthrax.

4. A client scheduled for surgery cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which best action regarding the informed consent?

• A. Obtain a court order for the surgery
• B. Sign the informed consent on behalf of the client
• C. Send the client to surgery without the consent form being signed
• D. Obtain a telephone consent from a family member, with the consent being witnessed by two healthcare providers

Correct answer: D

Rationale: In situations where a client is unable to sign the consent form, obtaining a telephone consent from a family member witnessed by two healthcare providers is the appropriate action to ensure informed consent is obtained. Option A is not necessary and involves legal proceedings. Option B is not ethical as the nurse cannot sign the consent on behalf of the client. Option C is unsafe and violates the client's rights by proceeding without proper consent.

5. In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?

• A. Secure a clean container
• B. Discard the container if the outside becomes soiled
• C. Rinse the client's mouth with water after collection
• D. Tell the client that 4 tablespoons of sputum are needed

Correct answer: A

Rationale: Corrected Rationale: Before sputum collection, it is crucial to use a clean container to prevent specimen contamination. This step is essential to ensure accurate test results and to avoid introducing external particles or bacteria into the sample. Choice B is incorrect because discarding the container if the outside becomes soiled is not a standard practice before collection. Choice C is incorrect as rinsing the client's mouth with Listerine after collection can introduce unnecessary substances into the specimen. Choice D is incorrect as the amount of sputum needed should be determined by the healthcare provider, not the client.

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