Nursing Elites

1. A client recovering from abdominal surgery is on a clear liquid diet. The nurse should identify which of the following as the most appropriate food choice for this diet?

• A. Chicken noodle soup
• B. Grape juice
• C. Cream of wheat
• D. Vanilla pudding

Correct answer: B

Rationale: Grape juice is the most appropriate choice for a clear liquid diet as it is a transparent fluid that is easily digested. Clear liquid diets aim to provide fluids and electrolytes while being easy on the digestive system. Choices A, C, and D are not suitable for a clear liquid diet as they are not in liquid form or do not meet the criteria of being easily digestible for someone recovering from abdominal surgery. Chicken noodle soup, cream of wheat, and vanilla pudding are not considered clear liquids and may not be well-tolerated by a client who has undergone abdominal surgery.

2. While caring for a client with bilateral chest tubes, the bubbling in the water-seal chamber of the right chest tube stops. What action is most important for the nurse to take?

• A. Check the chest tube connections to the water-seal container
• B. Replace the water-seal collection container
• C. Increase the amount of wall suction connected to the right chest tube
• D. Milk the tubing connected to the right chest tube

Correct answer: A

Rationale: The most important action for the nurse to take when the bubbling in the water-seal chamber of the right chest tube stops is to check the chest tube connections to the water-seal container. This is crucial to ensure there are no disconnections or leaks affecting the bubbling. Replacing the water-seal collection container (choice B) is not necessary unless there is a malfunction; increasing suction (choice C) without assessing the connections can be harmful, and 'milking' the tubing (choice D) is an inappropriate action that can cause damage to the system.

3. A client is admitted with the diagnosis of Wernicke’s syndrome. What assessment finding should the nurse use in planning the client’s care?

• A. Right lower abdominal pain
• B. Confusion
• C. Depression
• D. Peripheral neuropathy

Correct answer: B

Rationale: Confusion is a key symptom of Wernicke’s syndrome, which is due to thiamine deficiency. Wernicke’s syndrome is characterized by a triad of symptoms known as the classic triad, which includes confusion, ataxia, and ophthalmoplegia. Right lower abdominal pain, depression, and peripheral neuropathy are not typically associated with Wernicke’s syndrome, making them incorrect choices for this question.

4. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?

• A. Remind the client of the importance of using a rescue inhaler for asthma management
• B. Leave the client alone to process his thoughts about the inhaler
• C. Ask the client what he is thinking about at that moment
• D. Pause and inquire if the client has any questions or needs clarification

Correct answer: C

Rationale: In this scenario, the most appropriate action for the nurse to take is to ask the client what he is thinking about at that moment. By doing so, the nurse can understand the client's concerns or distractions, which can then be addressed effectively during the teaching session. Option A is incorrect as it assumes the client is not paying attention due to forgetfulness about the importance of the inhaler, which may not be the case. Option B is incorrect because leaving the client alone without addressing the issue does not facilitate effective learning. Option D, although closer, does not directly address the client's distraction and may not uncover the underlying issue causing the lack of focus.

5. An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been “trying to start a new business” and is “too busy to eat.” He is alert and oriented to time, place and person, but not situation. Which nursing diagnosis has the greatest priority?

• A. Self-care deficit
• B. Disturbed sleep pattern
• C. Disturbed thought processes
• D. Imbalanced nutrition

Correct answer: D

Rationale: Imbalanced nutrition is the priority in this case as the patient has lost a significant amount of weight and is neglecting self-care, such as bathing and eating properly. The weight loss indicates a serious issue that needs immediate attention to prevent further health complications. While self-care deficit, disturbed sleep pattern, and disturbed thought processes are also concerns for this patient, addressing the imbalanced nutrition takes precedence due to the potential impact on the patient's physical health. Neglecting proper nutrition can lead to serious complications, so it is crucial to address this issue first.

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