Nursing Elites

1. A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should the nurse include?

• A. Weigh the client weekly to monitor for fluid retention.
• B. Monitor the client's blood glucose level every 6 hours.
• C. Change the TPN tubing every 72 hours.
• D. Flush the TPN line with sterile water before and after administration.

Correct answer: B

Rationale: The correct answer is B: Monitor the client's blood glucose level every 6 hours. When a client is on TPN, it is crucial to monitor their blood glucose levels frequently to prevent complications such as hyperglycemia or hypoglycemia. Weighing the client weekly to monitor for fluid retention (choice A) is important but not as critical as monitoring blood glucose levels. Changing the TPN tubing every 72 hours (choice C) is important for infection control but does not directly relate to the client's metabolic status. Flushing the TPN line with sterile water before and after administration (choice D) is not a standard practice and may introduce contaminants into the TPN solution.

2. What is the best position for a patient in respiratory distress?

• A. Semi-Fowler's position
• B. Trendelenburg position
• C. Prone position
• D. Supine position

Correct answer: A

Rationale: The best position for a patient in respiratory distress is the Semi-Fowler's position. This position promotes lung expansion and eases breathing by allowing the chest to expand more fully. The Trendelenburg position (choice B) where the patient's feet are higher than the head is not recommended in respiratory distress as it may cause increased pressure on the chest and reduced lung expansion. The prone position (choice C) lying on the stomach is also not optimal for respiratory distress as it can further compromise breathing. The supine position (choice D) lying flat on the back is not ideal as it may impair breathing by restricting chest expansion.

3. A client with a new diagnosis of celiac disease is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I can still have oatmeal for breakfast.
• B. I need to avoid foods that contain gluten.
• C. I can have rye toast with my eggs.
• D. I can continue to eat foods made from barley.

Correct answer: B

Rationale: The correct answer is B because clients with celiac disease should avoid gluten, which is found in foods like rye and barley. Choice A is incorrect because oatmeal may contain gluten unless specified gluten-free. Choice C is incorrect as rye contains gluten. Choice D is incorrect as barley contains gluten.

4. A nurse is reviewing the medical record of a client who has a prescription for spironolactone. Which of the following findings should the nurse report to the provider?

• A. Potassium 5.0 mEq/L
• B. Blood pressure 136/84 mm Hg
• C. Sodium 140 mEq/L
• D. Calcium 9.5 mg/dL

Correct answer: A

Rationale: A potassium level of 5.0 mEq/L is at the upper limit of normal and should be monitored closely in clients taking spironolactone, which is potassium-sparing. Elevated potassium levels can lead to hyperkalemia, especially in individuals on potassium-sparing diuretics like spironolactone. Monitoring and reporting high potassium levels are crucial to prevent potential complications such as cardiac arrhythmias. Blood pressure (choice B), sodium level (choice C), and calcium level (choice D) are not directly related to the use of spironolactone and do not require immediate reporting in this scenario.

5. A nurse in a mental health facility receives a change of shift report on four clients. Which of the following clients should the nurse plan to assess first?

• A. Client placed in restraints due to aggressive behavior
• B. A new client with a history of 4.5 kg weight loss in the past two months
• C. Client receiving PRN dose of haloperidol 2 hours ago for anxiety
• D. Client receiving first ECT treatment today

Correct answer: A

Rationale: The nurse should plan to assess the client placed in restraints due to aggressive behavior first. Clients in restraints require immediate attention and frequent monitoring for safety. While weight loss, medication administration, and ECT treatment are important, the client in restraints is in a critical situation that requires immediate assessment and intervention.

Similar Questions