Nursing Elites

1. A client has a closed wound drainage system. Which of the following actions should the nurse take?

• A. Avoid pressing the container down to create a vacuum
• B. Wear sterile gloves while handling the drainage system
• C. Reset the container with the drainage port closed
• D. Maintain the drain in a dependent position to facilitate drainage

Correct answer: D

Rationale: In a closed wound drainage system, it is essential to maintain the drain in a dependent position to allow for proper drainage. Gravity aids in the flow of drainage, preventing fluid backflow or pooling. Avoiding pressing the container down to create a vacuum (Choice A) is crucial as it can lead to complications in the system. Wearing sterile gloves (Choice B) is important for infection control when handling the drainage system. Resetting the container with the drainage port closed (Choice C) is incorrect as it can cause spillage and contamination of the surrounding area.

2. The healthcare provider is caring for a client receiving total parenteral nutrition (TPN). Which laboratory value should be monitored closely to assess for complications?

• A. Serum sodium
• B. Serum calcium
• C. Blood urea nitrogen (BUN)
• D. Blood glucose

Correct answer: D

Rationale: The correct answer is D: Blood glucose. Monitoring blood glucose levels is crucial for clients receiving total parenteral nutrition (TPN) due to the high glucose content in TPN solutions. TPN delivers essential nutrients, including glucose, directly into the bloodstream. Clients on TPN are at risk of developing hyperglycemia due to the concentrated glucose infusion. Therefore, close monitoring of blood glucose levels is necessary to detect and prevent hyperglycemia-related complications such as osmotic diuresis, hyperosmolarity, and electrolyte imbalances. While serum sodium, serum calcium, and blood urea nitrogen (BUN) levels are important parameters in various clinical scenarios, they are not specifically associated with TPN administration. These values are not the primary indicators to assess for complications in clients receiving TPN.

3. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B: 'Glasgow Coma Scale 8, respirations regular.' A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deep state of unconsciousness, which may not be accurate in this case. Choice C is incorrect as stating the client 'appears to be sleeping' may not accurately reflect the severity of the situation. Choice D is incorrect because a Glasgow Coma Scale of 13 would not typically correspond to a non-responsive state.

4. When assessing a client's skin turgor, a nurse should:

• A. Grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression
• B. Check skin elasticity on the back of the hand
• C. Press on the skin over the abdomen
• D. Measure skin turgor on the lower leg

Correct answer: A

Rationale: Correct answer: When assessing a client's skin turgor, a nurse should grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression. This method is reliable for evaluating hydration status as it is less influenced by age-related skin changes or adipose tissue. Choice B, checking skin elasticity on the back of the hand, is not the preferred method for assessing skin turgor. Choice C, pressing on the skin over the abdomen, is not a standard location for assessing skin turgor. Choice D, measuring skin turgor on the lower leg, is not a recommended site for assessing skin turgor in clinical practice.

5. A client is receiving 0.9% sodium chloride IV at 125 mL/hr. The nurse notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?

• A. Reposition the client
• B. Document the client's IV intake in the medical record
• C. Request a new IV fluid prescription
• D. Check the IV tubing for obstruction

Correct answer: D

Rationale: The correct answer is to check the IV tubing for obstruction. The first step in the nursing process is assessment. By checking the IV tubing for obstruction, the nurse can assess and potentially correct any issues affecting the flow rate. This action may help to ensure that the prescribed infusion rate is maintained. Repositioning the client is not the priority at this stage as the issue seems related to the IV tubing. Documenting the intake or requesting a new prescription are not immediate actions needed to address the current situation with the IV fluid flow.

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