Nursing Elites

1. What is the primary nursing action for a patient with confusion post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Monitor vital signs
• D. Check oxygen saturation

Correct answer: A

Rationale: Administering oxygen is the primary nursing action for a patient with confusion post-surgery because it helps address any potential hypoxia that may be contributing to the patient's confusion. While repositioning the patient, monitoring vital signs, and checking oxygen saturation are important nursing interventions, administering oxygen takes precedence in ensuring adequate oxygenation levels, which is crucial in managing post-surgery confusion.

2. A client with chronic kidney disease is being educated by a nurse about dietary modifications. Which of the following client statements indicates an understanding of the teaching?

• A. I will increase my intake of potassium-rich foods.
• B. I will limit my protein intake to prevent further kidney damage.
• C. I will avoid consuming foods high in phosphorus.
• D. I will increase my intake of dairy products to support kidney function.

Correct answer: B

Rationale: The correct answer is B. Limiting protein intake is crucial for clients with chronic kidney disease as it helps prevent further kidney damage. Increasing intake of potassium-rich foods (choice A) is not recommended for clients with kidney disease as high potassium levels can be harmful. Avoiding foods high in phosphorus (choice C) is important, but limiting protein intake is a higher priority. Increasing dairy product intake (choice D) is not ideal for clients with kidney disease as they may need to monitor their phosphorus intake from such foods.

3. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the unit due to a staffing shortage. Which of the following clients should the nurse delegate to the LPN?

• A. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs.
• B. A client who sustained a concussion and has unequal pupils.
• C. A client who is postoperative following a bowel resection with an NG tube.
• D. A client who fractured his femur yesterday and is experiencing shortness of breath.

Correct answer: C

Rationale: The correct answer is C because a client who is postoperative following a bowel resection with an NG tube can be delegated to an LPN as this involves routine postoperative care. Option A involves administering packed RBCs which requires assessment and monitoring for potential adverse reactions, not suitable for delegation to an LPN. Option B requires neurological assessment and close monitoring due to the concussion, which is beyond the scope of an LPN. Option D involves a client with a recent fracture and shortness of breath, which requires urgent assessment and intervention beyond the LPN's scope of practice.

4. A nurse is providing dietary teaching to a client with irritable bowel syndrome (IBS). Which dietary recommendation should be included?

• A. Consume food high in bran fiber.
• B. Increase intake of milk products.
• C. Sweeten foods with fructose corn syrup.
• D. Increase foods high in gluten.

Correct answer: A

Rationale: The correct answer is A: Consume food high in bran fiber. Bran fiber helps reduce IBS symptoms by promoting regular bowel movements. Choices B, C, and D are incorrect because increasing milk products can exacerbate symptoms in some individuals with IBS, sweetening foods with fructose corn syrup may worsen symptoms due to its high FODMAP content, and increasing foods high in gluten could be problematic for individuals with gluten sensitivities or celiac disease, which are common in some with IBS.

5. A nurse is preparing to administer an enema to a client. Which of the following actions should the nurse take?

• A. Place the client in a high-Fowler's position
• B. Assist the client to the left Sims' position
• C. Insert the enema tubing 2.5 cm (1 in) into the rectum
• D. Lubricate the tip of the enema tubing with petroleum jelly

Correct answer: B

Rationale: The correct answer is to assist the client to the left Sims' position when administering an enema. This position helps facilitate the flow of the enema solution into the rectum. Placing the client in a high-Fowler's position (Choice A) is not ideal for administering an enema. Inserting the enema tubing 2.5 cm (1 in) into the rectum (Choice C) is incorrect as it should be inserted 7.5-10 cm (3-4 in) for an adult. Lubricating the tip of the enema tubing with petroleum jelly (Choice D) is a correct step to ease insertion but is not the most critical action among the choices provided.

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