Nursing Elites

1. When digitally evacuating stool from a client with a fecal impaction, what action should the nurse take?

• A. Insert a lubricated gloved finger and advance along the rectal wall
• B. Apply lubricant and stimulate peristalsis
• C. Apply pressure to the abdomen to assist with removal
• D. Increase fluid intake before the procedure

Correct answer: A

Rationale: The correct action when digitally evacuating stool from a client with a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma to the client. Choice B is incorrect because stimulating peristalsis is not the appropriate action for digitally evacuating stool. Choice C is incorrect as applying pressure to the abdomen can be uncomfortable and ineffective. Choice D is also incorrect because increasing fluid intake is not directly related to the digital evacuation procedure.

2. A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?

• A. Place the infant under a radiant warmer
• B. Move the probe site every 3 hours
• C. Heat the skin one minute prior to placing the probe
• D. Place a sensor on the index finger

Correct answer: B

Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures accurate readings. Placing the infant under a radiant warmer (Choice A) is not necessary for pulse oximetry monitoring. Heating the skin before placing the probe (Choice C) can potentially cause burns in infants. Placing a sensor on the index finger (Choice D) is not the standard practice for continuous pulse oximetry in infants.

3. A client with osteoporosis is being taught about dietary management. Which of the following foods should be recommended?

• A. Almonds
• B. Spinach
• C. Yogurt
• D. Carrots

Correct answer: C

Rationale: Yogurt is a calcium-rich food that helps strengthen bones and should be recommended to clients with osteoporosis. Almonds, spinach, and carrots do not provide as much calcium as yogurt and are not as beneficial for individuals with osteoporosis.

4. A nurse is teaching a newly licensed nurse about using a portable oxygen system. What instruction should the nurse include?

• A. The oxygen should be kept in a storage room when not in use.
• B. Turn off the oxygen when not in use.
• C. Check the oxygen level regularly using a pulse oximeter.
• D. Never leave the oxygen running when transporting a client.

Correct answer: C

Rationale: The correct answer is to check the oxygen level regularly using a pulse oximeter. This instruction is crucial as it ensures safe and adequate oxygenation for the client. Option A is incorrect as oxygen should not be stored in a storage room but in a well-ventilated area. Option B is not ideal as oxygen should be left on unless otherwise specified by a healthcare provider. Option D is also important but not directly related to the primary instruction of monitoring oxygen levels.

5. A client sustained a major burn over 20% of the body. What intervention should the nurse implement to meet the client's nutritional needs?

• A. Keep track of calorie intake for food and beverages.
• B. Provide a low-protein, high-carbohydrate diet.
• C. Schedule meals at 6-hour intervals.
• D. Provide a high-protein, high-calorie diet.

Correct answer: D

Rationale: The correct answer is to provide a high-protein, high-calorie diet for a client with major burns. This type of diet is essential to support healing and recovery. High-protein intake is crucial as it helps in tissue repair and wound healing, while high-calorie intake is necessary to meet the increased metabolic demands of the body during the healing process. Keeping track of calorie intake (Choice A) is important but doesn't address the specific needs of a burn patient. Providing a low-protein, high-carbohydrate diet (Choice B) is not suitable for burn patients as they require adequate protein for wound healing. Scheduling meals at 6-hour intervals (Choice C) may be helpful for maintaining a consistent eating schedule, but it is not as crucial as providing the correct high-protein, high-calorie diet.

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