Nursing Elites

1. A nurse is caring for a client following an appendectomy. The nurse verifies the postoperative prescription which reads, 'Discontinue NPO status; advance diet as tolerated.' Which of the following are appropriate for the nurse to offer the client? (SATA)

• A. Wheat toast
• B. Applesauce
• C. Applesauce, Chicken broth
• D. Chicken broth

Correct answer: C

Rationale: The correct answer is C: Applesauce and chicken broth. After an appendectomy, patients are typically started on a clear liquid diet before advancing to more solid foods. Applesauce and chicken broth are part of a low-residue diet that is easily digestible and gentle on the digestive system, making them suitable choices for a client following surgery. Wheat toast may be too heavy and fibrous initially, while other solid foods should be introduced gradually to prevent gastrointestinal upset.

2. A client receiving total parenteral nutrition (TPN) suddenly develops tremors, dizziness, and diaphoresis. The client said, 'I feel weak and the bag was empty.' Which is the most likely complication the client is currently experiencing?

• A. Fluid volume overload
• B. Sepsis
• C. Hyperglycemia
• D. Hypoglycemia

Correct answer: D

Rationale: The client experiencing tremors, dizziness, diaphoresis, weakness, and stating that the TPN bag is empty is likely experiencing hypoglycemia. Hypoglycemia can occur when the TPN infusion suddenly stops, leading to a rapid drop in blood sugar levels. Symptoms of hypoglycemia include tremors, dizziness, diaphoresis, and weakness. Choices A, B, and C are incorrect as the symptoms presented are more consistent with hypoglycemia rather than fluid volume overload, sepsis, or hyperglycemia.

3. What is the medical term for a persistent, abnormal distortion of taste?

• A. Anosmia
• B. Dysgeusia
• C. Xerostomia
• D. Hypogeusia

Correct answer: B

Rationale: The correct answer is Dysgeusia, which is a persistent and abnormal distortion of the sense of taste. This condition can be triggered by various factors such as medications or certain diseases. Anosmia, choice A, refers to the loss of the sense of smell, not taste. Xerostomia, choice C, is the medical term for dry mouth, which is not specifically related to a distortion of taste. Hypogeusia, choice D, refers to a reduced ability to taste things, which is not the same as a distortion of the sense of taste.

4. You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT:

• A. Take the blood pressure reading on both arms for comparison
• B. Listen to and identify the phases of Korotkoff sounds
• C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
• D. Observe procedures for infection control

Correct answer: B

Rationale: When measuring blood pressure, it is crucial to follow specific steps to obtain accurate readings. Taking the blood pressure on both arms for comparison helps assess any variations. Pumping the cuff to around 50 mmHg above the point of pulse obliteration ensures accurate measurements. Observing procedures for infection control is vital to prevent the spread of infections. Listening to and identifying the phases of Korotkoff sounds are associated with auscultatory blood pressure measurements, not the initial blood pressure reading process.

5. During which step of the nursing process does the nurse analyze data related to the patient's health status?

• A. Assessment
• B. Implementation
• C. Diagnosis
• D. Evaluation

Correct answer: A

Rationale: The correct answer is 'Assessment.' During the assessment phase of the nursing process, the nurse collects and analyzes data related to the patient's health status. This involves gathering information through various means such as patient interviews, physical examinations, and reviewing medical records. Choice B, 'Implementation,' refers to the phase where the nurse carries out the planned interventions. Choices C and D, 'Diagnosis' and 'Evaluation,' come after the assessment phase in the nursing process.

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