Nursing Elites

1. A nurse is caring for a client with encephalopathy secondary to liver failure. The client has been prescribed a high-calorie, low-protein diet. Which of the following meal selections is appropriate for this client?

• A. Scrambled eggs, bacon, and pancakes
• B. Grilled cheese sandwich, potato chips, chocolate pudding
• C. Steak, French fries, corn
• D. Chicken breast, mashed potatoes, spinach

Correct answer: D

Rationale: The correct answer is D: Chicken breast provides a low-fat protein source, and mashed potatoes and spinach provide high-calorie nutrients suitable for managing liver failure. Option A (Scrambled eggs, bacon, and pancakes) is high in protein, which is not suitable for a low-protein diet. Option B (Grilled cheese sandwich, potato chips, chocolate pudding) contains high protein and may not be appropriate for the client. Option C (Steak, French fries, corn) is high in protein and fat, which are not recommended for this client's dietary requirements.

2. A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states:

• A. I will make sure my medications are enteric-coated
• B. My stoma will drain liquid continuously
• C. I will change my pouch system every two weeks
• D. My stoma size will stay the same after it heals

Correct answer: B

Rationale: The correct answer is B. When a client with an ileostomy states that their stoma will drain liquid continuously, it indicates an understanding of the expected outcome. In an ileostomy, the stoma continuously drains liquid stool as it bypasses the large intestine where water is absorbed. Choices A, C, and D are incorrect because ensuring medications are enteric-coated, changing the pouch system every two weeks, and expecting the stoma size to remain the same after healing are not accurate statements related to an ileostomy.

3. A client with staphylococcus epidermidis is prescribed vancomycin. Identify the adverse effect associated with this antibiotic therapy.

• A. Hepatotoxicity
• B. Constipation
• C. Infusion reaction
• D. Immunosuppression

Correct answer: C

Rationale: The correct adverse effect associated with vancomycin therapy is an infusion reaction, known as Red Man Syndrome. This reaction presents with rashes, flushing, tachycardia, and hypotension. It is essential to administer vancomycin over at least 60 minutes to prevent these symptoms. Hepatotoxicity, constipation, and immunosuppression are not commonly associated with vancomycin use. Ototoxicity and renal toxicity are significant risks with prolonged vancomycin therapy.

4. A client has been prescribed ferrous sulfate. Which instruction should the nurse provide to the client?

• A. Avoid strawberries, citrus fruits, and melon to improve absorption
• B. Take with fluids other than coffee or tea
• C. Take on a full stomach
• D. Double the dose if you miss a dose one day

Correct answer: B

Rationale: The correct instruction the nurse should provide to a client prescribed ferrous sulfate is to take it with fluids other than coffee or tea. Coffee and tea can inhibit iron absorption. Therefore, choices A, C, and D are incorrect. Avoiding strawberries, citrus fruits, and melon is not necessary for improving absorption of ferrous sulfate, taking it on a full stomach is not recommended, and doubling the dose if a dose is missed can lead to an overdose.

5. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?

• A. Blood glucose of 150 mg/dL
• B. Urine output of 20 mL per hour
• C. Systolic blood pressure of 140 mm Hg
• D. BUN 20 mg/dL

Correct answer: B

Rationale: A urine output of 20 mL per hour is low and indicates renal insufficiency, a sign of magnesium sulfate toxicity. The medication is excreted by the kidneys, so toxicity can occur if renal function declines. Blood glucose of 150 mg/dL is within normal range and not indicative of magnesium sulfate toxicity. A systolic blood pressure of 140 mm Hg is elevated but not specifically related to magnesium sulfate toxicity. A BUN level of 20 mg/dL is also within normal limits and not a sign of medication toxicity.

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