Nursing Elites

1. A nurse is caring for a client who is receiving TPN. Which of the following actions should the nurse take to prevent infection?

• A. Change the TPN tubing every 72 hours.
• B. Monitor the client's blood glucose every 4 hours.
• C. Monitor the client's urine output every 8 hours.
• D. Use sterile technique when changing the central line dressing.

Correct answer: D

Rationale: The correct answer is D: 'Use sterile technique when changing the central line dressing.' When caring for a client receiving TPN, it is crucial to maintain aseptic technique to prevent infections. Changing the central line dressing with sterile technique helps reduce the risk of introducing pathogens into the client's system. Choices A, B, and C are incorrect because changing the TPN tubing every 72 hours, monitoring blood glucose, and monitoring urine output are important aspects of care but are not directly related to preventing infection in clients receiving TPN.

2. A patient is 1 day postoperative following a hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the hip?

• A. Keep the patient in a side-lying position.
• B. Place a pillow between the patient's legs.
• C. Instruct the patient to avoid sitting for long periods.
• D. Elevate the head of the bed to 90 degrees.

Correct answer: B

Rationale: Placing a pillow between the patient's legs is the correct action to prevent dislocation of the hip following arthroplasty. This technique helps maintain proper alignment and stability of the hip joint. Keeping the patient in a side-lying position may not provide the necessary support to prevent hip dislocation. Instructing the patient to avoid sitting for long periods is important for preventing complications like deep vein thrombosis but does not directly prevent hip dislocation. Elevating the head of the bed to 90 degrees is not relevant to preventing hip dislocation in a postoperative hip arthroplasty patient.

3. A nurse is teaching a client who is at 10 weeks gestation about the amniocentesis procedure. Which of the following statements should the nurse make?

• A. This test will confirm whether your baby has a genetic disorder.
• B. Amniocentesis is used to assess your baby's lung maturity.
• C. You should not feel any pain during this procedure.
• D. This test will assess the amount of amniotic fluid around your baby.

Correct answer: A

Rationale: The correct answer is A because amniocentesis is a procedure that confirms genetic disorders by analyzing the amniotic fluid surrounding the baby. Choice B is incorrect because amniocentesis is not used to assess lung maturity. Choice C is incorrect because some discomfort or pain may be felt during the procedure. Choice D is incorrect because amniocentesis does not primarily assess the amount of amniotic fluid around the baby.

4. A client is receiving chemotherapy and is being taught about preventing infection. Which of the following instructions should the nurse include?

• A. Take your temperature daily.
• B. Avoid fresh fruits and vegetables.
• C. Limit your intake of high-protein foods.
• D. Increase your intake of high-fat foods.

Correct answer: B

Rationale: Clients receiving chemotherapy are instructed to avoid fresh fruits and vegetables to lower the risk of infection. Fresh produce may harbor bacteria or other pathogens that could be harmful to individuals with compromised immune systems. Taking the temperature daily may be important but is not directly related to preventing infection. Limiting high-protein foods is not necessary unless there are specific dietary restrictions due to the treatment plan. Increasing the intake of high-fat foods is not recommended during chemotherapy as a high-fat diet may lead to other health issues.

5. A healthcare professional is reviewing the laboratory results of a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the professional report to the provider?

• A. Blood glucose level of 130 mg/dL
• B. Serum sodium level of 140 mEq/L
• C. Serum potassium level of 3.2 mEq/L
• D. Platelet count of 250,000/mm³

Correct answer: C

Rationale: A serum potassium level of 3.2 mEq/L indicates hypokalemia, a complication that should be reported in clients receiving TPN. Hypokalemia can lead to serious cardiac and neuromuscular complications. The other options are within normal ranges and do not indicate immediate concerns for a client receiving TPN. A blood glucose level of 130 mg/dL, serum sodium level of 140 mEq/L, and platelet count of 250,000/mm³ are all considered normal values and do not require immediate intervention.

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