Nursing Elites

1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as a possible complication of TPN administration?

• A. Pitting edema of bilateral lower extremities
• B. Hypoactive bowel sounds in all four quadrants
• C. Weight is the same as the day before
• D. Bilateral posterior lung sounds are diminished

Correct answer: A

Rationale: The correct answer is A: Pitting edema of bilateral lower extremities. Pitting edema can indicate fluid overload, which is a potential complication of TPN administration. Choice B, hypoactive bowel sounds, is more indicative of a gastrointestinal issue rather than a complication of TPN. Choice C, weight remaining the same, is expected to remain stable with proper TPN administration. Choice D, diminished lung sounds, is not directly related to TPN administration and is more suggestive of a respiratory issue.

2. A client with Ménière's disease is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan of care?

• A. Maintain strict bed rest
• B. Restrict fluid intake to the morning hours
• C. Administer aspirin
• D. Provide a low sodium diet

Correct answer: D

Rationale: The correct intervention for a client with Ménière's disease experiencing vertigo is to provide a low sodium diet. This helps reduce fluid retention, which can alleviate the symptoms of Ménière's disease. Maintaining strict bed rest is not necessary and can lead to deconditioning. Restricting fluid intake to the morning hours does not specifically address the underlying cause of Ménière's disease. Administering aspirin is not indicated for Ménière's disease and can potentially worsen symptoms.

3. What should the nurse monitor for in a patient with hypokalemia?

• A. Monitor for muscle weakness
• B. Check deep tendon reflexes (DTRs)
• C. Monitor for seizures
• D. Monitor for bradycardia

Correct answer: A

Rationale: The correct answer is to monitor for muscle weakness in a patient with hypokalemia. Hypokalemia, which is low potassium levels, can lead to muscle weakness due to its effects on neuromuscular function. Checking deep tendon reflexes (Choice B) is not typically associated with hypokalemia. Seizures (Choice C) are more commonly associated with low calcium levels rather than low potassium levels. Bradycardia (Choice D) is a symptom of hyperkalemia (high potassium levels) rather than hypokalemia.

4. A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement?

• A. Place several pillows behind the client's head
• B. Place the client in a Sim's position
• C. Keep the client's neck in a midline position
• D. Maintain flexion of the client's hips at a 90° angle

Correct answer: C

Rationale: Keeping the client's neck in a midline position is crucial for managing increased intracranial pressure. This position helps optimize blood flow and minimizes the risk of further increasing ICP. Placing several pillows behind the client's head (Choice A) may inadvertently elevate the head, potentially worsening ICP. Placing the client in a Sim's position (Choice B) or maintaining flexion of the client's hips at a 90° angle (Choice D) are not directly related to managing increased ICP.

5. If a nurse misread a glucose reading as 210 mg/dL instead of 120 mg/dL and administered insulin, what should the nurse monitor for?

• A. Monitor for hypoglycemia
• B. Monitor for hyperglycemia
• C. Administer glucose IV
• D. Document the incident

Correct answer: A

Rationale: The correct answer is to monitor for hypoglycemia. In this scenario, the nurse administered insulin based on an incorrect glucose reading, which could lead to a drop in blood sugar levels. Monitoring for hypoglycemia is crucial to prevent any adverse effects on the patient's health. Choice B, monitoring for hyperglycemia, is incorrect as the administration of insulin can lead to low blood sugar levels, not high. Choice C, administering glucose IV, is not the immediate action needed as monitoring for hypoglycemia comes first. Choice D, documenting the incident, is important but not the initial priority when patient safety is at risk.

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