Nursing Elites

1. A 4-year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?

• A. Notify the healthcare provider
• B. Readjust the traction
• C. Administer the ordered PRN medication
• D. Reassess the foot in fifteen minutes

Correct answer: A

Rationale: In this situation, a pale foot with the absence of a pulse indicates compromised circulation, which is a critical emergency. The nurse should immediately notify the healthcare provider to address the circulation issue promptly. Reading the question and understanding the urgency is vital. Readjusting the traction, administering PRN medication, or waiting to reassess the foot in fifteen minutes are not appropriate actions when a child is experiencing compromised circulation.

2. A nurse is reinforcing dietary teaching with a client who has a burn injury and adheres to a strict vegan diet. Which of the following food choices should the nurse recommend?

• A. Tuna salad
• B. Fresh fruit
• C. Vegetables
• D. Beans

Correct answer: D

Rationale: Beans are an excellent choice for a client with a burn injury who follows a strict vegan diet. They are a rich source of protein, essential for healing, making them the most suitable option among the choices provided. Tuna salad (choice A) is not suitable for a vegan diet as it contains animal products. While fresh fruit (choice B) and vegetables (choice C) are healthy options, they may not provide sufficient protein needed for healing from a burn injury.

3. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?

• A. Stay with the client and observe for airway obstruction
• B. Collect pillows and pad the side rails of the bed
• C. Place an oral airway in the mouth and suction
• D. Announce a cardiac arrest and assist with intubation

Correct answer: A

Rationale: The correct action for the nurse to take next is to stay with the client and observe for airway obstruction. This is crucial as it ensures immediate intervention if there is any airway compromise. Choice B is incorrect as padding the side rails of the bed is not the priority in this situation. Choice C is incorrect because inserting an oral airway and suctioning should only be done if there is evidence of airway obstruction, and it is not the initial step. Choice D is incorrect as announcing a cardiac arrest and assisting with intubation is not the immediate action needed when a client is seizing and losing consciousness.

4. What should a client with diarrhea avoid consuming?

• A. Orange juice
• B. Tuna
• C. Eggs
• D. Macaroni

Correct answer: A

Rationale: A client with diarrhea should avoid consuming orange juice. Orange juice is high in sugar content, which can worsen diarrhea symptoms by drawing water into the intestines, potentially leading to further dehydration and discomfort. Tuna, eggs, and macaroni are generally well-tolerated and do not exacerbate diarrhea symptoms, making them more suitable food choices for individuals experiencing diarrhea.

5. A client who is 2 days postoperative following abdominal surgery is transitioning from a clear liquid diet to a full liquid diet. The nurse should remind the client that which of the following items is included in a full liquid diet?

• A. Creamed peas
• B. Cottage cheese
• C. Chocolate pudding
• D. Applesauce

Correct answer: C

Rationale: The correct answer is C, chocolate pudding. A full liquid diet consists of smooth, creamy foods like pudding. Creamed peas (choice A) are not typically allowed on a full liquid diet as they may contain solid pieces. Cottage cheese (choice B) and applesauce (choice D) are also not part of a full liquid diet as they are not in liquid form.

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