Nursing Elites

1. A client receiving total parenteral nutrition (TPN) suddenly develops tremors, dizziness, and diaphoresis. The client said, 'I feel weak and the bag was empty.' Which is the most likely complication the client is currently experiencing?

• A. Fluid volume overload
• B. Sepsis
• C. Hyperglycemia
• D. Hypoglycemia

Correct answer: D

Rationale: The client experiencing tremors, dizziness, diaphoresis, weakness, and stating that the TPN bag is empty is likely experiencing hypoglycemia. Hypoglycemia can occur when the TPN infusion suddenly stops, leading to a rapid drop in blood sugar levels. Symptoms of hypoglycemia include tremors, dizziness, diaphoresis, and weakness. Choices A, B, and C are incorrect as the symptoms presented are more consistent with hypoglycemia rather than fluid volume overload, sepsis, or hyperglycemia.

2. The mentally ill person responds positively to the nurse who is warm and caring. This is a demonstration of the nurse’s role as:

• A. counselor
• B. mother surrogate
• C. therapist
• D. socializing agent

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

3. What is the term for intestinal wounds associated with Crohn's disease that develop in different areas in the intestine, with normal tissue separating affected regions?

• A. Skip lesions
• B. Fistulas
• C. Fissures
• D. Loop ulcerations

Correct answer: A

Rationale: Skip lesions are typical characteristics of Crohn's disease, where patches of diseased intestine are interspersed with areas of healthy tissue. This is why option A is the correct answer. Option B, fistulas, are abnormal connections between two body parts, which is not what the question is describing. Option C, fissures, are small tears in the lining of the anus, which also do not fit the description in the question. Option D, loop ulcerations, is not a recognized medical term, making it an incorrect choice.

4. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:

• A. Amount of food and fluid taken during the last meal before treatment
• B. Respiratory rate, breath sounds, and location of congestion
• C. Teaching the client's relatives to perform the procedure
• D. Doctor's order regarding position restrictions and client's tolerance for lying flat

Correct answer: B

Rationale: The correct answer is B because when assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on various aspects such as the amount of food and fluid taken before treatment to prevent complications during the procedure, teaching the client's relatives to perform the procedure correctly, and following the doctor's orders regarding position restrictions and the client's tolerance for lying flat. Respiratory rate, breath sounds, and location of congestion would be assessed during the procedure itself, not as part of the pre-assessment.

5. _____ neutralizes stomach acid in the small intestine:

• A. saliva
• B. gastric mucus
• C. bicarbonate ions
• D. enzymes

Correct answer: C

Rationale: The correct answer is C: bicarbonate ions. Bicarbonate ions, secreted by the pancreas, neutralize the acidic chyme entering the small intestine from the stomach, creating a more suitable environment for digestive enzymes. Saliva (choice A) helps in the initial breakdown of food in the mouth, not in neutralizing stomach acid. Gastric mucus (choice B) protects the stomach lining from the acidic environment but does not neutralize the acid in the small intestine. Enzymes (choice D) facilitate chemical reactions in digestion but do not neutralize stomach acid.

Similar Questions