Nursing Elites

1. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?

• A. Applesauce
• B. Mashed potatoes
• C. Orange slices
• D. Soft bread

Correct answer: C

Rationale: The correct answer is C: Orange slices. Orange slices contain membranes that are difficult to swallow, which can pose a risk to clients on a mechanical soft diet. This type of diet is designed for individuals who have difficulty chewing or swallowing. Choices A, B, and D are suitable for a mechanical soft diet as they are soft in texture and easy to chew and swallow.

2. A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

• A. Apply skin preparation to wound edges
• B. Cleanse the wound with normal saline
• C. Don sterile gloves
• D. Determine the client's pain level

Correct answer: D

Rationale: The correct answer is to determine the client's pain level first. Assessing the client's pain is crucial before proceeding with any procedure, including dressing changes. This step ensures that appropriate pain management measures can be implemented, making the wound care process as comfortable as possible for the patient. Applying skin preparation to wound edges (choice A) can come after addressing the pain. While cleansing the wound with normal saline (choice B) and donning sterile gloves (choice C) are important steps in wound care, they should follow the assessment of the client's pain level to prioritize the patient's comfort and well-being.

3. While caring for a client receiving patient-controlled analgesia (PCA), which of the following interventions should the nurse take?

• A. Encourage the client to use the PCA before dressing changes.
• B. Monitor the client's respiratory status.
• C. Provide oxygen therapy to the client as needed.
• D. Ensure the PCA pump is functioning properly.

Correct answer: A

Rationale: Corrected Rationale: The nurse should encourage the client to use the PCA pump before activities like dressing changes, which are likely to cause pain, to ensure effective pain management. Monitoring the client's respiratory status (Choice B) is important but not the priority in this scenario. Providing oxygen therapy (Choice C) is not a routine intervention for all clients on PCA unless specifically indicated. Ensuring the PCA pump is functioning properly (Choice D) is essential, but encouraging the client to use the PCA before painful activities takes precedence to manage pain effectively.

4. A nurse providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?

• A. A peanut butter sandwich on wheat bread
• B. A sliced apple and red grapes
• C. A chocolate chip cookie with a glass of skim milk
• D. A scrambled egg with cheddar cheese

Correct answer: B

Rationale: The correct answer is B. Clients with phenylketonuria (PKU) must adhere to a strict low-phenylalanine diet to prevent neurological damage. Foods high in phenylalanine such as peanut butter, wheat bread, chocolate chip cookies, milk, scrambled eggs, and cheddar cheese should be avoided. Sliced apples and red grapes are low in phenylalanine, making them safe choices for individuals with PKU. Choice A (peanut butter sandwich on wheat bread), Choice C (chocolate chip cookie with a glass of skim milk), and Choice D (scrambled egg with cheddar cheese) are all high in phenylalanine and should be avoided by individuals with PKU.

5. A nurse is assessing a client who has a history of atrial fibrillation and is receiving warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the warfarin?

• A. Platelet count
• B. International normalized ratio (INR)
• C. Bleeding time
• D. Partial thromboplastin time (PTT)

Correct answer: B

Rationale: The correct answer is B: International normalized ratio (INR). The INR is used to monitor the effectiveness of warfarin therapy. A higher INR indicates a longer time it takes for the blood to clot, which is desirable in patients receiving warfarin to prevent blood clots. Platelet count (Choice A) assesses the number of platelets in the blood and is not directly related to warfarin therapy. Bleeding time (Choice C) evaluates the time it takes for a person to stop bleeding after a standardized wound, but it is not specific to monitoring warfarin effectiveness. Partial thromboplastin time (PTT) (Choice D) is more commonly used to monitor heparin therapy, not warfarin.

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