Nursing Elites

1. Which serum laboratory value should the nurse monitor carefully for a client who has had an NG tube for suctioning for the past week?

• A. White blood cell count
• B. Albumin
• C. Calcium
• D. Sodium

Correct answer: D

Rationale: The nurse should carefully monitor serum sodium levels for a client with an NG tube on suction for an extended period due to potential fluid loss and the risk of developing hyponatremia, an electrolyte imbalance. Hyponatremia can occur as a result of continual suctioning leading to fluid loss, making it crucial to monitor sodium levels to prevent complications associated with low sodium levels. Monitoring white blood cell count, albumin, or calcium is not directly related to the impact of NG tube suction on fluid and electrolyte balance, so these values are not the priority in this scenario.

2. A client is receiving total parenteral nutrition (TPN). Which assessment finding is most concerning to the nurse?

• A. Blood glucose level of 150 mg/dL.
• B. Blood pressure of 110/70 mm Hg.
• C. Serum albumin level of 3.5 g/dL.
• D. The client's temperature is 100.4°F (38°C).

Correct answer: D

Rationale: A temperature of 100.4°F (38°C) (D) is the most concerning finding for a client receiving total parenteral nutrition (TPN) as it may indicate an infection, which poses a significant risk. Monitoring blood glucose level (A), blood pressure (B), and serum albumin (C) are also important, but an elevated temperature suggests a potential serious complication that requires immediate attention.

3. The healthcare provider plans to foster a therapeutic relationship with the patient utilizing therapeutic techniques of communication. It is most important that the provider:

• A. Work on establishing rapport with the patient.
• B. Use humor to lighten emotionally charged topics of discussion.
• C. Empathize with the patient when the patient shares sad feelings.
• D. Demonstrate respect when discussing emotionally charged topics.

Correct answer: D

Rationale: In fostering a therapeutic relationship, demonstrating respect is essential as it helps the patient feel valued and understood. Respectful communication contributes to building trust and a safe environment for open and honest discussions.

4. Warm compresses are ordered for an open wound. Which action is appropriate for the nurse?

• A. Use sterile technique when applying the compresses.
• B. Leave the compresses on the area continuously, pouring warm solution on the area when it cools down.
• C. Alternate warm compresses with cold compresses.
• D. Apply a wet dressing and cover it with a dry dressing.

Correct answer: A

Rationale: Using sterile technique when applying the compresses is crucial to prevent infection and promote wound healing. Ensuring a clean environment during wound care reduces the risk of introducing pathogens that can lead to complications. Proper infection control measures play a significant role in the healing process of open wounds. Choice B is incorrect because leaving the compresses on continuously can lead to skin damage or thermal injury. Choice C is incorrect as alternating warm compresses with cold compresses is not appropriate for an open wound. Choice D is incorrect as applying a wet dressing without following specific orders can be detrimental to wound healing.

5. The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?

• A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
• B. Sit quietly in the client's room until the client leaves the bathroom.
• C. Allow the client to cry alone and leave the client in the bathroom.
• D. Talk to the client and attempt to find out why the client is crying.

Correct answer: D

Rationale: When encountering a client in distress, the nurse's initial response should be to communicate with the client to assess the situation and provide support. By talking to the client and attempting to find out the reason for their distress, the nurse can offer appropriate assistance and ensure the client's well-being. This action prioritizes the client's emotional needs and helps establish a therapeutic relationship, which is essential in nursing care.

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