Nursing Elites

1. When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?

• A. Creamy peanut butter
• B. Vegetable juice
• C. Clear beef broth
• D. Canned fruit cocktail

Correct answer: E

Rationale: The correct answer should be provided as choice E: Vanilla frozen yogurt. For a postoperative full liquid diet, the nurse should encourage the client to eat foods that are fully liquid and easy to digest. Vanilla frozen yogurt is a suitable choice as it provides calories and nutrients while being in a liquid form. Creamy peanut butter, vegetable juice, and canned fruit cocktail are not appropriate for a full liquid diet as they are not fully liquid and may not be easy to digest. Creamy peanut butter is solid, vegetable juice is not fully liquid, and canned fruit cocktail contains solid pieces.

2. When washing soiled hands, what should the nurse do after wetting the hands and applying soap?

• A. Rub hands palm to palm
• B. Interlace the fingers
• C. Dry hands with a paper towel
• D. Turn off the water faucet

Correct answer: A

Rationale: After wetting the hands and applying soap, the nurse should rub hands palm to palm. Rubbing hands palm to palm helps create friction and effectively clean the hands by spreading the soap and reaching all areas. Interlacing the fingers, drying hands with a paper towel, and turning off the water faucet should come after rubbing hands palm to palm in the handwashing process. Interlacing the fingers can be done to ensure the backs of the hands are cleaned, drying hands with a paper towel is the final step to ensure hands are dry, and turning off the water faucet helps save water.

3. When administering ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention by the nurse?

• A. Headache
• B. Pruritus
• C. Nausea
• D. Stridor

Correct answer: D

Rationale: Stridor is a high-pitched, noisy breathing sound that can indicate a serious condition like airway obstruction or a severe allergic reaction, necessitating immediate intervention to maintain the client's airway and prevent further complications. While headache, pruritus, and nausea are important to assess and manage, they are not as immediately life-threatening as stridor, which requires prompt attention to prevent respiratory compromise.

4. The client had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?

• A. Insert an indwelling urinary catheter
• B. Monitor for the appearance of an incisional hernia
• C. Instruct the client to eat small frequent meals
• D. Measure hourly urinary output

Correct answer: D

Rationale: Monitoring hourly urinary output is crucial during the first 24 postoperative hours to assess kidney function, fluid balance, and early detection of complications like dehydration or inadequate kidney perfusion. Inserting an indwelling urinary catheter is not routinely necessary after gastric bypass surgery unless there are specific indications. Monitoring for an incisional hernia is important but not the highest priority in the immediate postoperative period. Instructing the client to eat small frequent meals is essential for long-term dietary management after gastric bypass surgery, but not the most critical intervention during the initial 24 hours.

5. The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately?

• A. Change the dressing using a compression bandage
• B. Test fluid on the dressing for glucose
• C. Document the findings in the electronic medical record
• D. Mark drainage area with a pen and continue to monitor

Correct answer: B

Rationale: The correct action for the nurse to implement immediately upon identifying clear fluid on the surgical dressing post-lumbar surgery is to test the fluid for glucose. Clear fluid could indicate cerebrospinal fluid (CSF) leakage, and testing for glucose can help confirm this. Changing the dressing using a compression bandage (Choice A) without further assessment could lead to complications. Documenting the findings (Choice C) is important but not as immediate as confirming the presence of CSF. Marking the drainage area with a pen and monitoring (Choice D) does not address the need for immediate confirmation of CSF leakage.

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