Nursing Elites

1. A client receiving total parenteral nutrition (TPN) is experiencing nausea and vomiting. What is the nurse's first action?

• A. Check the client's blood glucose level.
• B. Decrease the rate of TPN infusion.
• C. Administer an antiemetic as prescribed.
• D. Check the client's TPN bag for solution accuracy.

Correct answer: D

Rationale: The correct first action for the nurse to take when a client receiving TPN is experiencing nausea and vomiting is to check the client's TPN bag for solution accuracy. This is crucial to ensure that the correct solution is being administered and to address any potential errors. Checking the blood glucose level or administering an antiemetic may be necessary interventions but addressing the TPN bag's accuracy should be the priority to prevent any complications related to incorrect TPN solution.

2. The nurse is caring for a 69-year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?

• A. Test blood sugar every 2 hours using Accu-Chek
• B. Review signs of hyperglycemia with the family and client
• C. Administer insulin if the blood sugar is elevated
• D. Measure the client's urine output

Correct answer: D

Rationale: The correct answer is D because measuring urine output is a task that falls within the UAP's scope of practice and does not require clinical decision-making. Choice A is incorrect because testing blood sugar using Accu-Chek involves interpreting results and possible adjustments, which require a licensed healthcare provider. Choice B is incorrect as discussing signs of hyperglycemia involves education and interpretation that should be done by a nurse. Choice C is incorrect since administering insulin is a high-risk task that necessitates precise dosing and monitoring, thus should not be delegated to UAP.

3. A client with adrenal insufficiency is admitted to the ICU with acute adrenal crisis. The client's vital signs include heart rate 138 bpm and BP 80/60. What is the nurse's first intervention?

• A. Obtain an analgesic prescription.
• B. Administer an IV fluid bolus.
• C. Administer PRN antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: The correct first intervention for a client with adrenal crisis and hypotension is to administer an IV fluid bolus. In adrenal crisis, the body is deficient in cortisol, leading to hypotension. Fluid resuscitation helps stabilize the blood pressure. Obtaining an analgesic prescription (Choice A) is not the priority in this situation. Administering a PRN antipyretic (Choice C) is not indicated as the client's vital signs do not suggest fever. Covering the client with a cooling blanket (Choice D) is not appropriate for addressing hypotension in adrenal crisis.

4. A client with a history of stroke is receiving warfarin. What is the nurse's priority assessment?

• A. Check the client's blood pressure.
• B. Assess for signs of bleeding.
• C. Assess the client's neurological status.
• D. Monitor the client's intake and output.

Correct answer: B

Rationale: The correct answer is to assess for signs of bleeding. Warfarin is an anticoagulant that increases the risk of bleeding in patients. Monitoring for signs of bleeding such as easy bruising, petechiae, blood in urine or stool, or unusual bleeding from gums is crucial. Checking the client's blood pressure (choice A) is important but not the priority in this situation. Assessing the client's neurological status (choice C) is essential in stroke patients but is not the priority related to warfarin therapy. Monitoring intake and output (choice D) is important for overall assessment but is not the priority when a client is on warfarin, as assessing for bleeding takes precedence.

5. A 48-year-old client with chronic alcoholism is admitted to the hospital. The nurse would anticipate that the client may be deficient in which vitamins?

• A. Vitamin B and vitamin C
• B. Vitamin D and vitamin E
• C. Vitamin K and vitamin A
• D. Vitamin A and vitamin E

Correct answer: A

Rationale: The correct answer is A. Chronic alcoholism commonly leads to deficiencies in B vitamins, particularly thiamine, and vitamin C. Thiamine deficiency can result in serious neurological issues like Wernicke-Korsakoff syndrome, while vitamin C deficiency can lead to scurvy. Choices B, C, and D are incorrect because vitamin D and E deficiencies are not typically associated with chronic alcoholism.

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