Nursing Elites

1. During an assessment, a client receiving tube feedings via NG tube shows signs of nasal mucosa irritation. What finding should the nurse report to the provider?

• A. Potassium 5.5 mEq/L
• B. Irritation of nasal mucosa
• C. Sodium 144 mEq/L
• D. Loose stools

Correct answer: B

Rationale: Irritation of nasal mucosa is a crucial finding that the nurse should report to the provider as it suggests potential complications with NG tube placement, such as improper positioning or mucosal damage. High potassium levels (Choice A) can be concerning but are not directly related to NG tube placement issues. Normal sodium levels (Choice C) and loose stools (Choice D) are common occurrences in clients receiving tube feedings and are not typically indicative of immediate complications that require urgent reporting.

2. A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?

• A. Fidelity
• B. Autonomy
• C. Beneficence
• D. Justice

Correct answer: A

Rationale: The correct answer is A: Fidelity. Fidelity in nursing ethics involves keeping promises and being faithful to commitments, demonstrating reliability and trustworthiness. In this scenario, the nurse is exemplifying fidelity by returning promptly to the client as promised. Choice B, Autonomy, refers to respecting a patient's right to make their own decisions, not relevant in this situation. Choice C, Beneficence, involves the duty to act in the best interest of the patient, which is not the primary focus here. Choice D, Justice, pertains to fairness and equity in the distribution of healthcare resources, not applicable to the nurse's actions in this case.

3. The patient refuses a morning bath, stating a preference for evening baths. What is the best action for the nurse to take?

• A. Defer the bath until evening and pass on the information to the next shift.
• B. Tell the patient that daily morning baths are the 'normal' routine.
• C. Explain the importance of maintaining morning hygiene practices.
• D. Cancel hygiene for the day and attempt again in the morning.

Correct answer: A

Rationale: The best action for the nurse is to respect the patient's preference and autonomy. By deferring the bath until evening, the nurse acknowledges and accommodates the patient's routine, promoting patient-centered care. Choice B could be seen as dismissive of the patient's preference and may not foster a therapeutic relationship. Choice C, while important, doesn't address the patient's current refusal. Choice D is not respectful of the patient's autonomy and could lead to increased resistance. Therefore, option A is the most appropriate and patient-centered approach.

4. The nurse is assessing a client who has just been admitted with a diagnosis of acute pancreatitis. Which finding is most important for the LPN/LVN to report to the healthcare provider immediately?

• A. Elevated serum lipase level
• B. Severe abdominal pain
• C. Nausea and vomiting
• D. Hypotension

Correct answer: D

Rationale: Hypotension is a critical finding that should be reported immediately in a client with acute pancreatitis as it may indicate severe complications such as hemorrhage or shock. While elevated serum lipase level, severe abdominal pain, and nausea/vomiting are common manifestations of acute pancreatitis, hypotension is a more urgent sign requiring immediate attention to prevent further deterioration. Hypotension can be a sign of significant fluid loss, hemorrhage, or sepsis, which are potentially life-threatening conditions that need prompt intervention. Elevated serum lipase levels, severe abdominal pain, and nausea/vomiting are important in the assessment of pancreatitis but do not indicate the same level of immediate danger as hypotension does.

5. The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?

• A. Infuse normal saline at a keep-vein-open rate.
• B. Discontinue the IV and flush the port with heparin.
• C. Infuse 10% dextrose and water at 54 ml/hr.
• D. Obtain a stat blood glucose level and notify the healthcare provider.

Correct answer: C

Rationale: Infusing 10% dextrose and water at 54 ml/hr is the correct action to prevent hypoglycemia until the next TPN solution becomes available. This solution will help maintain the client's glucose levels. Infusing normal saline at a keep-vein-open rate (Choice A) is not appropriate for maintaining glucose levels and would not address the nutritional needs provided by TPN. Discontinuing the IV and flushing the port with heparin (Choice B) is unnecessary and not indicated in this situation as the client still needs fluid and nutrition. Obtaining a stat blood glucose level and notifying the healthcare provider (Choice D) can be done later but is not the immediate action required when the TPN solution has run out.

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