Nursing Elites

1. During an excretory urogram, which observation made by the nurse indicates a complication?

• A. The client complains of a salty taste in the mouth when the dye is injected
• B. The client's entire body turns a bright red color
• C. The client states 'I have a feeling of getting warm.'
• D. The client gags and complains 'I am getting sick.'

Correct answer: B

Rationale: The observation of the client's entire body turning a bright red color during an excretory urogram indicates a severe reaction to the dye, which is a significant complication. This reaction is likely due to an allergic response and requires immediate medical attention. The other choices do not signify a severe complication: choice A could be a normal taste sensation related to the procedure, choice C may indicate a mild reaction, and choice D could be a common side effect of nausea without indicating a severe complication requiring immediate intervention.

2. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?

• A. Assess nail beds for color and refill
• B. Assess for postoperative arrhythmias
• C. Auscultate for pulmonary congestion
• D. Monitor equality of peripheral pulses

Correct answer: B

Rationale: Postoperative arrhythmias are a common and potentially serious complication after cardiac surgery, making them a priority to monitor. Assessing for postoperative arrhythmias takes precedence over other assessments like checking nail beds for color and refill, auscultating for pulmonary congestion, or monitoring peripheral pulses as arrhythmias can have immediate and severe implications for the child's health.

3. After surgery, a client has been taken off the ventilator and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

• A. Allow the client to melt ice chips in the mouth
• B. Provide mints to freshen the breath
• C. Perform frequent oral care with a tooth sponge
• D. Swab the mouth with glycerin swabs

Correct answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this situation. It helps maintain oral hygiene, prevent dryness, and provide comfort for a client with an NG tube. Allowing the client to melt ice chips may not be suitable immediately post-surgery due to potential risks. Providing mints or swabbing the mouth with glycerin swabs may not address the need for proper oral care and hygiene, which is essential for a client with an NG tube.

4. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250, and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?

• A. Diminished bowel sounds
• B. Loss of appetite
• C. A cold, pale lower leg
• D. Tachypnea

Correct answer: C

Rationale: A cold, pale lower leg is the most concerning finding as it indicates poor blood flow, potentially suggesting a serious circulatory problem that requires immediate attention. Diminished bowel sounds, loss of appetite, and tachypnea may be relevant but are not as indicative of a critical circulatory issue as a cold, pale lower leg.

5. A client is receiving teaching about a high-fiber diet to manage constipation. Which statement indicates the best choice for a high-fiber diet?

• A. Eating one medium apple is a good snack option.
• B. Selecting a ½ cup of sweet potatoes for starch is a great choice.
• C. Choosing a ½ cup of bran cereal for breakfast is ideal.
• D. Opting for 1 ounce of almonds when hungry midday is recommended.

Correct answer: C

Rationale: The correct answer is C because bran cereal is a high-fiber food that can effectively alleviate constipation by promoting regular bowel movements. Option A, an apple, while a healthy snack, may not provide as much fiber as bran cereal. Option B, sweet potatoes, are nutritious but may not be as high in fiber as bran cereal. Option D, almonds, are a good source of healthy fats and protein but do not provide as much fiber as bran cereal.

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