Nursing Elites

1. A client is receiving total parenteral nutrition (TPN). Which of these interventions should the nurse perform to reduce the risk of infection?

• A. Changing the TPN tubing and solution every 24 hours
• B. Monitoring the TPN infusion rate closely
• C. Keeping the head of the bed elevated
• D. Ensuring the solution is at room temperature before infusing

Correct answer: A

Rationale: The correct answer is to change the TPN tubing and solution every 24 hours to reduce the risk of infection. This practice helps prevent microbial growth and contamination in the TPN solution. Monitoring the infusion rate closely (choice B) is important for preventing metabolic complications but does not directly reduce the risk of infection. Keeping the head of the bed elevated (choice C) is beneficial for preventing aspiration in feeding tube placement but is unrelated to reducing infection risk in TPN. Ensuring the solution is at room temperature before infusing (choice D) is essential for patient comfort and preventing metabolic complications but does not specifically address infection risk reduction.

2. The nurse is caring for a client post appendectomy. The client has developed a fever, and the incision site is red and swollen. Which of these assessments is a priority for the nurse to perform?

• A. Check the client's blood pressure
• B. Assess the client's pain level
• C. Inspect the incision site
• D. Monitor the client's respiratory status

Correct answer: C

Rationale: Inspecting the incision site is a priority in this situation because the redness and swelling indicate a potential infection. This assessment helps the nurse determine the extent of infection and the appropriate intervention, such as administering antibiotics or notifying the healthcare provider. Checking the client's blood pressure (Choice A) may be important but is not the priority in this scenario where signs of infection are present. Assessing the client's pain level (Choice B) is also important but addressing the infection takes precedence. Monitoring the client's respiratory status (Choice D) is essential but not the priority when dealing with a localized infection at the incision site.

3. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?

• A. The tube will drain fluid from your chest.
• B. The tube will remove excess air from your chest.
• C. The tube controls the amount of air that enters your chest.
• D. The tube will seal the hole in your lung.

Correct answer: B

Rationale: The correct answer is B: 'The tube will remove excess air from your chest.' In a spontaneous pneumothorax, air accumulates in the pleural space, causing lung collapse. The chest tube is inserted to remove this excess air, allowing the lung to re-expand. Choices A, C, and D are incorrect because the primary purpose of a chest tube in pneumothorax is to evacuate air, not fluid, control air entry, or seal a lung hole.

4. A client with a history of seizures is being monitored with an electroencephalogram (EEG). Which of these interventions should the nurse perform to prepare the client for the test?

• A. Instruct the client to avoid caffeine for 8 hours before the test
• B. Explain the procedure to the client and obtain consent
• C. Administer anticonvulsant medication as ordered
• D. Instruct the client to wash their hair the morning of the test

Correct answer: A

Rationale: Instructing the client to avoid caffeine for 8 hours before the EEG is essential. This intervention helps ensure accurate test results by preventing stimulation of the nervous system, which could interfere with the interpretation of the brain's electrical activity. Explaining the procedure and obtaining consent are important steps but do not directly impact the test results. Administering anticonvulsant medication as ordered is a medical intervention and not a preparation step for the test. Instructing the client to wash their hair the morning of the test is not necessary for EEG preparation.

5. A nurse is reinforcing dietary teaching with a client who has a burn injury and adheres to a strict vegan diet. Which of the following food choices should the nurse recommend?

• A. Tuna salad
• B. Fresh fruit
• C. Vegetables
• D. Beans

Correct answer: D

Rationale: Beans are an excellent choice for a client with a burn injury who follows a strict vegan diet. They are a rich source of protein, essential for healing, making them the most suitable option among the choices provided. Tuna salad (choice A) is not suitable for a vegan diet as it contains animal products. While fresh fruit (choice B) and vegetables (choice C) are healthy options, they may not provide sufficient protein needed for healing from a burn injury.

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