Nursing Elites

1. When reinforcing teaching about self-care with a patient who has pelvic inflammatory disease and does not speak English, what action by the nurse is appropriate?

• A. Provide written instructions in English.
• B. Use family members as translators.
• C. Seek assistance from a facility-approved interpreter.
• D. Use online translation tools.

Correct answer: C

Rationale: When communicating with a patient who does not speak English, it is crucial to seek assistance from a facility-approved interpreter. Using family members as translators can lead to inaccuracies, breaches in confidentiality, and discomfort for the patient. Online translation tools may not provide accurate or context-specific translations, which can result in misunderstandings. Providing written instructions in English would not be effective if the patient does not understand the language.

2. A nurse is preparing to administer total parenteral nutrition (TPN) to a client. Which of the following findings indicates a need to obtain a new bag of TPN before administering?

• A. The TPN solution has an oily appearance and a layer of fat on top of the solution.
• B. The TPN solution contains added electrolytes, vitamins, and trace elements.
• C. The bag of TPN was prepared by the pharmacy 12 hours prior.
• D. The bag of TPN is labeled with the client's name, medical record number, and prescription.

Correct answer: A

Rationale: A TPN solution with an oily appearance and a layer of fat on top indicates that the solution is 'cracked' and should not be used as it may have separated or deteriorated. This finding suggests a need to obtain a new bag of TPN before administering. Options B, C, and D are normal aspects of TPN administration. Option B confirms the presence of essential components in the TPN solution, option C provides information about the preparation time, and option D ensures proper identification and matching of the TPN with the correct client.

3. A nurse is reviewing laboratory results for a client who has chronic kidney disease. Which of the following findings should the nurse expect?

• A. Hypernatremia
• B. Hypocalcemia
• C. Low potassium
• D. Low magnesium

Correct answer: B

Rationale: In chronic kidney disease, the kidneys have impaired ability to activate vitamin D, leading to decreased production of calcitriol. Calcitriol is essential for calcium absorption in the intestines. Therefore, hypocalcemia is a common finding in chronic kidney disease. Hypernatremia (increased sodium levels) is not typically associated with chronic kidney disease. Low potassium and low magnesium are possible electrolyte imbalances in chronic kidney disease, but they are not as directly related to the impaired activation of vitamin D as hypocalcemia.

4. A nurse is caring for a newborn who has a blood glucose level of 45 mg/dL. Which of the following actions should the nurse take?

• A. Encourage the mother to breastfeed the newborn
• B. Gavage feed 60 mL (2 oz) of glucose water
• C. Administer 10 mL of D5W via IV
• D. Recheck the glucose level in 2 hours

Correct answer: A

Rationale: Encouraging the mother to breastfeed the newborn is the most appropriate action in this scenario. Breastfeeding can quickly raise blood glucose levels in newborns. A blood glucose level of 45 mg/dL is often acceptable in newborns, but close monitoring is necessary. Gavage feeding with glucose water or administering D5W via IV may not be necessary at this point and could lead to potential risks of overfeeding or hypoglycemia. Rechecking the glucose level in 2 hours may delay necessary intervention, as breastfeeding can promptly address the low blood glucose levels.

5. A client who is at 24 weeks of gestation is being taught about the signs of preterm labor. Which of the following should the nurse include?

• A. Sudden weight loss
• B. Regular contractions
• C. Shortness of breath
• D. Vaginal spotting

Correct answer: B

Rationale: The correct answer is B: Regular contractions. Regular contractions before 37 weeks of gestation are a significant sign of preterm labor. It is essential for clients to be aware of this symptom and report it promptly to their healthcare provider. Choices A, C, and D are incorrect because sudden weight loss, shortness of breath, and vaginal spotting are not typical signs of preterm labor. Teaching clients about the specific signs of preterm labor can help in early detection and intervention, ultimately improving outcomes for both the client and the baby.

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