Nursing Elites

1. While assessing a client with fluid volume deficit, which of the following findings should the nurse expect?

• A. Bradycardia
• B. Increased skin turgor
• C. Dry mucous membranes
• D. Hypertension

Correct answer: C

Rationale: Dry mucous membranes are a classic clinical manifestation of fluid volume deficit. Dehydration leads to reduced fluid intake or excessive fluid loss, resulting in decreased moisture in the mucous membranes. Bradycardia, increased skin turgor, and hypertension are not typically associated with fluid volume deficit. Bradycardia is more commonly seen in conditions like hypothyroidism or increased intracranial pressure. Increased skin turgor is a sign of dehydration, not deficit. Hypertension is not a typical finding in fluid volume deficit.

2. What action is required by law when preparing to administer a controlled substance?

• A. Verify the client’s identification using two identifiers.
• B. Document the medication administration in the client’s chart immediately.
• C. Return any unused portion of the medication to the pharmacy.
• D. Have a second nurse witness the disposal of any unused portion.

Correct answer: D

Rationale: Having a second nurse witness the disposal of any unused portion of a controlled substance is a legal requirement to ensure proper disposal, prevent diversion, and maintain accountability. This practice helps in reducing the risk of misuse or unauthorized access to controlled substances, enhancing patient safety, and complying with legal regulations and standards.

3. A client has a new prescription for total parenteral nutrition (TPN). Which of the following actions should the nurse plan to take?

• A. Obtain a random blood glucose daily.
• B. Change the IV tubing every 72 hours.
• C. Apply a new dressing to the IV site every 24 hours.
• D. Weigh the client weekly.

Correct answer: A

Rationale: When a client is on total parenteral nutrition (TPN), monitoring blood glucose levels daily is crucial to manage and detect complications like hyperglycemia, which can occur due to the high glucose content in TPN solutions. Regular blood glucose monitoring helps the healthcare team adjust the TPN infusion rate to maintain optimal glucose levels and prevent adverse events. Choices B, C, and D are incorrect because changing IV tubing every 72 hours, applying a new dressing to the IV site every 24 hours, and weighing the client weekly are not specific actions directly related to monitoring and managing the effects of TPN, particularly in relation to glucose levels.

4. A client is receiving continuous enteral feedings. Which of the following interventions should the nurse implement?

• A. Monitor intake and output every 8 hours.
• B. Flush the feeding tube every 4 hours.
• C. Measure the client's temperature every 24 hours.
• D. Change the feeding bag and tubing every 72 hours.

Correct answer: B

Rationale: The correct answer is B: Flush the feeding tube every 4 hours. Flushing the feeding tube every 4 hours is essential to maintain patency and prevent clogging, ensuring the client receives the prescribed enteral nutrition without interruption. This intervention helps prevent complications such as tube occlusion. Monitoring intake and output is important for assessing the client's hydration status but does not directly address tube patency. Measuring the client's temperature is essential for monitoring for signs of infection but is not directly related to tube maintenance. Changing the feeding bag and tubing every 72 hours is important for infection control but does not address tube patency.

5. A healthcare professional is educating a client with osteoporosis about dietary management. Which of the following foods should the professional recommend?

• A. Green beans
• B. Fortified cereal
• C. Red meat
• D. White bread

Correct answer: B

Rationale: Fortified cereal is the correct answer as it is an excellent choice for individuals with osteoporosis due to its high calcium and vitamin D content, both essential nutrients for bone health. These nutrients help in maintaining bone density and strength, which is crucial for individuals with osteoporosis. Green beans (choice A) do not provide as much calcium and vitamin D as fortified cereal. Red meat (choice C) is a good source of protein but is not as rich in calcium and vitamin D compared to fortified cereal. White bread (choice D) lacks the essential nutrients needed for bone health, making it a less suitable choice for individuals with osteoporosis.

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