Nursing Elites

1. When supporting the psychosocial needs of a client experiencing negative side effects associated with chemotherapy, which intervention is most appropriate?

• A. Read the client's discharge instructions well in advance of dismissal
• B. Provide medications to reduce nausea and vomiting
• C. Give simple instructions about self-care while in the hospital
• D. Determine the levels of support from significant others

Correct answer: D

Rationale: When a client is experiencing negative side effects associated with chemotherapy, addressing their psychosocial needs is crucial. One effective intervention is to determine the levels of support from significant others. This involves assessing the family, spouse, or friends who can provide help and support to the client when healthcare providers are not present. By identifying and organizing these resources, the nurse can help alleviate fears about the future, prepare caregivers for the client's needs, and facilitate a smoother transition for the client upon discharge. Reading discharge instructions, providing medications, or giving self-care instructions, although important, do not directly address the psychosocial needs of the client during this challenging time.

2. The clinic nurse is obtaining data about a child with a diagnosis of lactose intolerance. Which data should the nurse expect to obtain on assessment?

• A. Reports of frothy stools and diarrhea
• B. Reports of foul-smelling ribbon stools
• C. Reports of profuse, watery diarrhea and vomiting
• D. Reports of diffuse abdominal pain unrelated to meals or activity

Correct answer: A

Rationale: Lactose intolerance commonly presents with frothy stools and diarrhea due to the inability to digest lactose. Other symptoms include abdominal distension, crampy abdominal pain, and excessive flatus. Foul-smelling ribbon stools are indicative of Hirschsprung's disease, not lactose intolerance. Profuse, watery diarrhea and vomiting are more characteristic of celiac disease. Diffuse abdominal pain unrelated to meals or activity is a typical symptom of irritable bowel syndrome, not lactose intolerance.

3. A client with asthma has low-pitched wheezes present in the final half of exhalation. One hour later, the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client:

• A. Has increased airway obstruction.
• B. Has improved airway obstruction.
• C. Needs to be suctioned.
• D. Exhibits hyperventilation.

Correct answer: B

Rationale: The change from low-pitched wheezes to high-pitched wheezes indicates a shift from larger to smaller airway obstruction, suggesting increased narrowing of the airways. This change signifies a progression or worsening of the airway obstruction. The absence of evidence of secretions does not support the need for suctioning. Hyperventilation is characterized by rapid and deep breathing, which is not indicated by the information provided in the question.

4. The nurse caring for Mrs. J is prepared to suction her endotracheal tube. Which of the following interventions will reduce hypoxia during this procedure?

• A. Hyperoxygenate Mrs. J for up to 60 seconds prior to starting
• B. Administer 15 mL of sterile fluid into the tube prior to suctioning
• C. Suction for no longer than 30 seconds at a time
• D. Wait 30 seconds after suctioning before attempting again

Correct answer: A

Rationale: Before suctioning a client's endotracheal tube, it is essential to hyperoxygenate the client for approximately 30 to 60 seconds. Hyperoxygenation helps increase oxygen delivery to the tissues, reducing the risk of hypoxia during and after the suctioning procedure. Administering fluid into the tube before suctioning (Choice B) is unnecessary and can lead to complications. Suctioning for no longer than 30 seconds at a time (Choice C) is a general guideline but does not specifically address reducing hypoxia. Waiting 30 seconds after suctioning before attempting again (Choice D) may lead to inadequate oxygenation and potential hypoxia, making it less effective in preventing this complication compared to hyperoxygenation prior to suctioning.

5. Which food should the assistive personnel be instructed to remove from the child's food tray based on the prescribed treatment for nephrotic syndrome?

• A. Pickle
• B. Wheat toast
• C. Baked chicken
• D. Steamed vegetables

Correct answer: A

Rationale: In nephrotic syndrome, a no-added-salt diet is recommended to manage the condition. High-sodium foods like pickles should be avoided as they can exacerbate fluid retention and swelling. Wheat toast, baked chicken, and steamed vegetables are generally suitable for individuals with nephrotic syndrome as they are low in sodium and protein, which are important considerations for this condition. Therefore, the correct choice is to remove the pickles from the child's food tray.

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