Nursing Elites

1. A teenage client is admitted to the hospital because of an acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs?

• A. lungs
• B. liver
• C. kidneys
• D. adrenal glands

Correct answer: B

Rationale: Acetaminophen is extensively metabolized in the liver. An acetaminophen overdose can lead to severe liver damage and even liver failure, which can be life-threatening. Choices A, C, and D are incorrect. Acetaminophen overdose does not typically cause life-threatening problems in the lungs, kidneys, or adrenal glands. While prolonged acetaminophen use may increase the risk of renal dysfunction, a single overdose primarily affects the liver.

2. Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?

• A. 0.9% sodium chloride
• B. 5% dextrose in water solution
• C. Sterile water
• D. Heparin sodium

Correct answer: A

Rationale: The correct answer is 0.9% sodium chloride. Normal saline is 0.9% sodium chloride, which has the same osmolarity as blood and does not cause cell lysis. Choices 2 and 3, 5% dextrose in water solution and sterile water, are hypotonic solutions that can lead to cell lysis. Choice 4, Heparin sodium, is an anticoagulant and is not routinely used to flush an IV device before and after the administration of blood.

3. While the client is receiving total parenteral nutrition (TPN), which lab test should be evaluated?

• A. Hemoglobin
• B. Creatinine
• C. Blood glucose
• D. White blood cell count

Correct answer: C

Rationale: When a client is receiving total parenteral nutrition (TPN), monitoring blood glucose levels is crucial as TPN solutions contain high amounts of glucose. This monitoring helps prevent hyperglycemia or hypoglycemia. Evaluating hemoglobin (choice A) is not directly related to TPN administration. Creatinine (choice B) is more relevant for assessing kidney function. White blood cell count (choice D) is important for evaluating immune function and infection, but not specifically tied to TPN administration.

4. Which nurse should be assigned to care for the postpartal client with preeclampsia?

• A. The nurse with 2 weeks of experience on the postpartum unit
• B. The nurse with 3 years of experience in labor and delivery
• C. The nurse with 10 years of experience in surgery
• D. The nurse with 1 year of experience in the neonatal intensive care unit

Correct answer: B

Rationale: The nurse with 3 years of experience in labor and delivery (answer B) should be assigned to care for the postpartal client with preeclampsia. This nurse has the most relevant experience and knowledge of possible complications associated with preeclampsia due to their background in labor and delivery. Assigning a nurse with only 2 weeks of experience on the postpartum unit (answer A) would not be suitable for handling the complexities of caring for a client with preeclampsia. Nurses with experience in surgery (answer C) or the neonatal intensive care unit (answer D) lack the specific expertise needed for managing a postpartal client with preeclampsia, making them unsuitable choices for this assignment.

5. Which of the following statements by a client with spinal cord injury indicates a need for further teaching by the nurse regarding bowel management?

• A. "I should avoid eating foods that produce gas."?
• B. "I should drink more fluids like water and non-caffeinated fruit juices."?
• C. "I should set a regular schedule for bowel movements."?
• D. "I should sit in an upright position for bowel movements."?

Correct answer: B

Rationale: The corrected statement indicates the need for further teaching because it suggests consuming fluids like fruit juices, which can include caffeinated options that may stimulate fluid loss through increased urination. It is more appropriate to emphasize the consumption of fluids like water and non-caffeinated fruit juices for proper hydration. Choices A, C, and D demonstrate a correct understanding of bowel management by focusing on dietary considerations, establishing a regular bowel movement schedule, and using proper positioning during bowel movements. Option B is incorrect as it may lead to increased fluid loss due to caffeine content in some fruit juices.

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