Nursing Elites

1. 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.

2. The nurse is monitoring a client who has just had a thyroidectomy. The client complains of tingling in the fingers and around the mouth. Which of these findings should the nurse assess first?

• A. Calcium level
• B. Chvostek's sign
• C. Trousseau's sign
• D. Serum potassium level

Correct answer: B

Rationale: The correct answer is B, Chvostek's sign. This is a classic sign of hypocalcemia, which can occur after a thyroidectomy due to injury or removal of the parathyroid glands. Hypocalcemia can lead to serious complications like tetany and laryngospasm, necessitating immediate attention. Assessing Chvostek's sign helps in early identification and management of hypocalcemia. Choices A, C, and D are not the priority in this situation. While assessing the calcium level is important for diagnosing hypocalcemia, the immediate concern is to identify clinical signs like Chvostek's sign, which indicate acute hypocalcemia. Trousseau's sign is also related to hypocalcemia but is not the most critical sign to assess first. Serum potassium level, although important for overall electrolyte balance, is not directly related to the client's current symptoms of tingling in the fingers and around the mouth.

3. A client with a head injury is being monitored for increased intracranial pressure. Which of these findings should be reported to the healthcare provider immediately?

• A. A heart rate of 72 beats per minute
• B. A blood pressure of 110/70 mm Hg
• C. Pupils equal and reactive to light
• D. Client reports headache

Correct answer: C

Rationale: The correct answer is C. Pupils that are equal and reactive to light are a crucial neurological assessment finding. Changes in pupil size and reactivity can indicate increased intracranial pressure, which requires immediate medical attention. Reporting this finding promptly allows for timely intervention to prevent further complications. Choices A, B, and D are within normal ranges and are not indicative of increased intracranial pressure. A heart rate of 72 beats per minute, blood pressure of 110/70 mm Hg, and a client reporting a headache are common findings and may not necessitate immediate intervention in this context.

4. A client is lactose intolerant, and a nurse is reinforcing teaching. Which of the following statements should the nurse include?

• A. You should increase the fiber in your diet.
• B. You should increase the calories in your diet.
• C. You should decrease the dairy products in your diet.
• D. You should decrease the amount of vitamin D in your diet.

Correct answer: C

Rationale: The correct statement for a client who is lactose intolerant is to decrease dairy products since lactose intolerant individuals should avoid dairy to prevent symptoms like bloating, diarrhea, and gas. Increasing fiber (Choice A) or calories (Choice B) is not directly related to lactose intolerance. Decreasing vitamin D (Choice D) is not necessary as lactose intolerance is about the sugar in dairy, not vitamin D.

5. During an excretory urogram, which observation made by the nurse indicates a complication?

• A. The client complains of a salty taste in the mouth when the dye is injected
• B. The client's entire body turns a bright red color
• C. The client states 'I have a feeling of getting warm.'
• D. The client gags and complains 'I am getting sick.'

Correct answer: B

Rationale: The observation of the client's entire body turning a bright red color during an excretory urogram indicates a severe reaction to the dye, which is a significant complication. This reaction is likely due to an allergic response and requires immediate medical attention. The other choices do not signify a severe complication: choice A could be a normal taste sensation related to the procedure, choice C may indicate a mild reaction, and choice D could be a common side effect of nausea without indicating a severe complication requiring immediate intervention.

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