Nursing Elites

1. A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following items should the nurse offer to the client?

• A. Tomato soup
• B. Apple juice
• C. Chicken broth
• D. Cranberry juice

Correct answer: C

Rationale: The correct answer is C, Chicken broth. A clear liquid diet includes clear fluids and foods that are liquid at room temperature. Chicken broth is allowed on a clear liquid diet as it is a clear liquid, while tomato soup, apple juice, and cranberry juice are not clear liquids. Tomato soup is a thicker substance and not allowed on a clear liquid diet. Apple juice and cranberry juice are also not clear liquids because they contain pulp and are not transparent like broth.

2. A client who is postpartum requests information about contraception. Which of the following instructions should the nurse include?

• A. The lactation amenorrhea method is effective for the first year postpartum.
• B. You should not use the diaphragm used before your pregnancy.
• C. Apply the transdermal birth control patch on your upper arm.
• D. Avoid using vaginal spermicides while breastfeeding.

Correct answer: D

Rationale: The correct answer is to advise the client to avoid using vaginal spermicides while breastfeeding. This instruction is important as spermicides can potentially affect the milk supply and cause irritation. Choice A is incorrect because the effectiveness of the lactation amenorrhea method diminishes after the first six months postpartum. Choice B is incorrect as using the diaphragm used before pregnancy may not fit properly due to changes in the body postpartum. Choice C is incorrect as the transdermal birth control patch is typically applied to the abdomen, buttocks, or upper torso, not specifically the upper arm.

3. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take?

• A. Allow the client enough time to perform rituals
• B. Give the client autonomy in scheduling activities
• C. Discourage the client from exploring irrational fears
• D. Provide negative reinforcement for ritualistic behaviors

Correct answer: A

Rationale: The correct intervention for a client with obsessive-compulsive disorder is to allow the client enough time to perform rituals. This helps manage anxiety and stress in individuals with OCD. Allowing time for rituals can provide a sense of control and reduce distress. Choice B, giving the client autonomy in scheduling activities, may not address the core symptoms of OCD related to rituals and compulsions. Choice C, discouraging the client from exploring irrational fears, goes against the principles of exposure therapy, which is a common treatment for OCD. Choice D, providing negative reinforcement for ritualistic behaviors, is not recommended as it can reinforce the behavior rather than help the client manage it.

4. A nurse is providing teaching to a client who is receiving radiation therapy for cancer of the larynx. Which of the following instructions should the nurse include?

• A. Apply heat to the neck to relieve pain.
• B. Use a soft-bristle toothbrush to prevent gum irritation.
• C. Rinse your mouth with an alcohol-free mouthwash twice daily.
• D. Wear loose-fitting clothing to protect your skin.

Correct answer: B

Rationale: The correct answer is to use a soft-bristle toothbrush to prevent gum irritation in clients undergoing radiation therapy for laryngeal cancer. Radiation therapy can cause oral mucositis and increase the risk of gum irritation, so using a soft-bristle toothbrush is recommended to minimize trauma to the gums and oral mucosa. Applying heat to the neck is contraindicated as it can exacerbate tissue damage caused by radiation. Rinsing the mouth with an alcohol-free mouthwash is preferred over an alcohol-based one to prevent drying and irritation of the oral mucosa. Wearing loose-fitting clothing is advised to prevent friction and irritation on the skin, rather than tight-fitting clothing that may cause pressure ulcers or skin breakdown.

5. How should fluid balance in a patient with heart failure be monitored?

• A. Monitor daily weight
• B. Monitor input and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: The correct answer is to monitor daily weight. Daily weight monitoring is crucial in assessing fluid balance in patients with heart failure because sudden weight gain can indicate fluid retention. Monitoring input and output (choice B) is important but may not provide a complete picture of fluid balance. Checking for edema (choice C) is a sign of fluid accumulation but may not be as accurate as daily weight monitoring. Monitoring blood pressure (choice D) is important in heart failure management but does not directly assess fluid balance.

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