Nursing Elites

1. A client receiving total parenteral nutrition (TPN) suddenly develops tremors, dizziness, and diaphoresis. The client said, 'I feel weak and the bag was empty.' Which is the most likely complication the client is currently experiencing?

• A. Fluid volume overload
• B. Sepsis
• C. Hyperglycemia
• D. Hypoglycemia

Correct answer: D

Rationale: The client experiencing tremors, dizziness, diaphoresis, weakness, and stating that the TPN bag is empty is likely experiencing hypoglycemia. Hypoglycemia can occur when the TPN infusion suddenly stops, leading to a rapid drop in blood sugar levels. Symptoms of hypoglycemia include tremors, dizziness, diaphoresis, and weakness. Choices A, B, and C are incorrect as the symptoms presented are more consistent with hypoglycemia rather than fluid volume overload, sepsis, or hyperglycemia.

2. Integrated management for childhood illness is the universal protocol of care endorsed by WHO and is used by different countries worldwide, including the Philippines. In any case that the nurse classifies the child and categorizes the signs and symptoms in the PINK category, you know that this means:

• A. Urgent referral
• B. Antibiotic Management
• C. Home treatment
• D. Outpatient treatment facility is needed

Correct answer: B

Rationale: When a child is classified under the PINK category in the Integrated Management of Childhood Illness (IMCI) guidelines, it signifies the need for antibiotic management. This category indicates severe signs and symptoms requiring immediate antibiotic treatment to address the underlying infection. Choices A, C, and D are incorrect because the PINK category specifically calls for urgent antibiotic management rather than urgent referral, home treatment, or outpatient treatment facility.

3. A nurse is caring for an antepartum client who has iron-deficiency anemia. When teaching the client about nutrition, the nurse should emphasize the need for an increased intake of which of the following foods?

• A. Milk and cheese
• B. Red meat and organ meat
• C. Fresh fruits
• D. Whole grain breads

Correct answer: B

Rationale: The correct answer is red meat and organ meat. These foods are rich sources of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Red meat and organ meat can significantly help in increasing the iron levels in individuals with iron-deficiency anemia, especially in antepartum clients. Fresh fruits, while nutritious, do not provide high amounts of iron. Milk and cheese are not the best sources of iron for individuals with iron-deficiency anemia. Whole grain breads also do not contain as much bioavailable iron as red meat and organ meat.

4. It is not a legally binding document but nevertheless, Very important in caring for the patients.

• A. BON Resolution No. 220 Series of 2002
• B. Patient’s Bill of Rights
• C. Nurse’s Code of Ethics
• D. Philippine Nursing Act of 2002

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. Before administration of blood and blood products, the nurse should first:

• A. Check with another R.N the client’s name, Identification number, ABO and RH type.
• B. Explain the procedure to the client
• C. Assess baseline vital signs of the client
• D. Check for the BT order

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

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