Nursing Elites

1. A nurse is reinforcing dietary teaching with a client who has a burn injury and adheres to a strict vegan diet. Which of the following food choices should the nurse recommend?

• A. Tuna salad
• B. Fresh fruit
• C. Vegetables
• D. Beans

Correct answer: D

Rationale: Beans are an excellent choice for a client with a burn injury who follows a strict vegan diet. They are a rich source of protein, essential for healing, making them the most suitable option among the choices provided. Tuna salad (choice A) is not suitable for a vegan diet as it contains animal products. While fresh fruit (choice B) and vegetables (choice C) are healthy options, they may not provide sufficient protein needed for healing from a burn injury.

2. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?

• A. Clamp the chest tube
• B. Call the surgeon immediately
• C. Prepare for blood transfusion
• D. Continue to monitor the rate of drainage

Correct answer: D

Rationale: In this scenario, the most appropriate nursing action is to continue to monitor the rate of drainage. Clamping the chest tube is not recommended as it can lead to a tension pneumothorax. Calling the surgeon immediately may not be necessary at this point unless the drainage rate significantly increases or other concerning symptoms develop. Preparing for a blood transfusion is premature without further assessment and monitoring of the client's condition. Monitoring the rate of drainage allows the nurse to assess for any potential complications and ensure that the drainage amount is within expected limits.

3. An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to

• A. administer the medication in 2 separate injections
• B. give the medication in the ventrogluteal site
• C. call to get a smaller volume ordered
• D. check with the pharmacy for a liquid form of the medication

Correct answer: A

Rationale: Administering the medication in 2 separate injections is the correct action. When the total volume of an injection is relatively large for a specific site, dividing it into smaller volumes and administering them separately is a safer practice to prevent discomfort, tissue damage, or absorption issues. Giving the medication in the ventrogluteal site can be appropriate for IM injections but does not address the issue of the total volume being too high for a single injection. Calling to get a smaller volume ordered may delay treatment and is not necessary when a safe administration method is available. Checking with the pharmacy for a liquid form of the medication does not directly address the issue of the total volume being too high for a single injection, and changing the formulation may not be necessary if the correct administration technique can be applied.

4. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to

• A. Call the health care provider immediately
• B. Administer acetaminophen as ordered as this is normal at this time
• C. Send blood, urine, and sputum for culture
• D. Increase the client's fluid intake

Correct answer: B

Rationale: In this scenario, the nurse should administer acetaminophen as ordered because a slight fever is normal after an MI. This intervention can help manage the fever unless other complications are present. Calling the health care provider immediately is not necessary for a slight fever post-MI. Sending blood, urine, and sputum for culture is not indicated solely based on a slight fever without other symptoms or signs of infection. Increasing fluid intake may be beneficial for various reasons but is not the priority in this situation where managing the fever with acetaminophen is appropriate.

5. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?

• A. Bruising at the operative site
• B. Elevated heart rate
• C. Decreased platelet count
• D. No bowel movement for 3 days

Correct answer: D

Rationale: The correct answer is D. Constipation is a common side effect of Tylenol #3, which contains codeine. Codeine can slow down bowel movements, leading to constipation. Monitoring for constipation and implementing management strategies is crucial. Choices A, B, and C are incorrect because bruising at the operative site, elevated heart rate, and decreased platelet count are not commonly associated side effects of Tylenol #3.

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