Nursing Elites

1. A nurse is teaching a client who has ulcerative colitis about dietary recommendations. Which of the following instructions should the nurse include?

• A. Avoid high-fiber foods
• B. Increase intake of spicy foods
• C. Consume foods high in fiber
• D. Eat large, infrequent meals

Correct answer: C

Rationale: The correct answer is C: 'Consume foods high in fiber.' Consuming high-fiber foods helps manage symptoms of ulcerative colitis by promoting regular bowel movements. Choices A, B, and D are incorrect. Avoiding high-fiber foods can worsen symptoms as fiber is beneficial for digestive health. Increasing the intake of spicy foods can exacerbate inflammation in the digestive tract, leading to more discomfort. Eating large, infrequent meals can put more strain on the digestive system, which is not ideal for managing ulcerative colitis.

2. A nurse is teaching a client who is undergoing chemotherapy about measures to prevent infection. Which of the following instructions should the nurse include?

• A. Avoid crowded places
• B. Wear a mask at home
• C. Drink unfiltered water
• D. Avoid washing hands frequently

Correct answer: A

Rationale: The correct instruction the nurse should include is to advise the client to avoid crowded places. Immunocompromised clients undergoing chemotherapy are at a higher risk of infections, so avoiding crowded places can help reduce exposure to pathogens. Wearing a mask at home is not necessary unless someone in the household is sick. Drinking unfiltered water can introduce harmful bacteria, increasing the risk of infection. Avoiding washing hands frequently is incorrect as hand hygiene is crucial in preventing the spread of infections.

3. While performing assessments on newborns in the nursery, which finding should the nurse report to the provider?

• A. A two-day old newborn with a respiratory rate of 70.
• B. A 16-hour old newborn who has not passed meconium yet.
• C. A two-day old newborn with a small amount of blood-tinged vaginal discharge.
• D. A 16-hour old newborn with a blood glucose of 45 mg/dL.

Correct answer: A

Rationale: A respiratory rate of 70 in a two-day old newborn is above the normal range and should be reported to the provider. This finding may indicate respiratory distress or another underlying issue that needs prompt attention. Choices B, C, and D are within normal limits for newborns and do not require immediate reporting to the provider.

4. How should a healthcare provider manage a patient with sepsis?

• A. Administer IV antibiotics
• B. Monitor vital signs
• C. Administer fluids
• D. All of the above

Correct answer: D

Rationale: Managing a patient with sepsis requires a multi-faceted approach. Administering IV antibiotics is crucial to combat the underlying infection. Monitoring vital signs such as heart rate, blood pressure, respiratory rate, and temperature helps assess the patient's response to treatment and identify any deterioration. Administering fluids is essential to maintain adequate blood pressure and organ perfusion. Therefore, all the options are integral components of sepsis management, making 'All of the above' the correct answer. Choices A, B, and C are all essential in the comprehensive care of a patient with sepsis. Omitting any of these aspects can lead to suboptimal outcomes, as each plays a critical role in addressing different aspects of sepsis management.

5. A nurse is caring for a client who has a chest tube following a thoracotomy. Which of the following findings should the nurse report to the provider?

• A. Drainage of 75 mL in the first hour after surgery.
• B. Constant bubbling in the water seal chamber.
• C. Tidaling in the water seal chamber.
• D. Client report of pain at the chest tube insertion site.

Correct answer: B

Rationale: Constant bubbling in the water seal chamber indicates an air leak, which should be reported to the provider. This finding suggests that the chest tube system is not functioning properly, leading to potential complications such as pneumothorax. Drainage of 75 mL in the first hour after surgery is within the expected range for a chest tube. Tidaling in the water seal chamber is a normal fluctuation and indicates proper functioning of the system. Client report of pain at the chest tube insertion site is expected after surgery and can be managed with appropriate pain management measures.

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