Nursing Elites

1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take to prevent infection?

• A. Monitor the client's electrolyte levels
• B. Change the TPN tubing every 24 hours
• C. Monitor blood glucose levels every 4 hours
• D. Administer insulin as prescribed

Correct answer: B

Rationale: The correct answer is B. Changing the TPN tubing every 24 hours is crucial in preventing infection by reducing the risk of bacterial contamination. Monitoring electrolyte levels (choice A) is essential but not directly related to preventing TPN-related infections. Monitoring blood glucose levels (choice C) is important for clients receiving TPN, but it is more related to glycemic control than infection prevention. Administering insulin as prescribed (choice D) is necessary for clients with diabetes but is not directly linked to preventing TPN-related infections.

2. A nurse is teaching a client who has peptic ulcer disease about preventing exacerbations. Which of the following instructions should the nurse include?

• A. Use antacids containing magnesium frequently
• B. Limit alcohol consumption
• C. Eat smaller, frequent meals
• D. Increase caffeine intake

Correct answer: B

Rationale: The correct answer is B: Limit alcohol consumption. Alcohol consumption can aggravate peptic ulcer disease by increasing gastric acid secretion, potentially leading to exacerbations. Choices A, C, and D are incorrect. Choice A is not recommended because antacids containing magnesium can interfere with other medications or conditions the client may have. Choice C is a good recommendation; however, it is not the priority instruction for preventing exacerbations. Choice D is also incorrect as caffeine can stimulate gastric acid secretion, which can worsen peptic ulcer disease.

3. The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see first?

• A. A 12-year-old oozing blood from a laceration on the left thumb due to a cut from a rusty metal can
• B. A 19-year-old with a fever of 103.8°F who is able to identify her sister but not the place and time
• C. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain
• D. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL

Correct answer: B

Rationale: The correct answer is B. A 19-year-old with a fever of 103.8°F who is confused and unable to orient to place and time likely has a severe infection or a serious medical condition affecting the central nervous system. This client needs immediate attention as altered mental status combined with a high fever can indicate a life-threatening situation. Choices A, C, and D present important conditions that require medical care, but they are not as urgent as the 19-year-old with a high fever and confusion. The 12-year-old with a laceration may require treatment for bleeding and a tetanus shot, the 49-year-old with a compound fracture needs urgent orthopedic intervention, and the 65-year-old with a high blood sugar is concerning for hyperglycemia but can wait momentarily compared to the client with a fever and altered mental status.

4. What is the recommended intervention for a patient experiencing severe hypoglycemia?

• A. Administer glucagon
• B. Provide a source of glucose
• C. Monitor blood sugar
• D. Assess vital signs

Correct answer: A

Rationale: Administering glucagon is the recommended intervention for severe hypoglycemia, especially when the patient is unconscious or unable to consume oral glucose. Glucagon helps increase blood glucose levels rapidly by stimulating the release of stored glucose from the liver. Providing a source of glucose (Choice B) can be challenging if the patient is unable to swallow or unconscious, making glucagon a more effective option. Monitoring blood sugar levels (Choice C) and assessing vital signs (Choice D) are important aspects of managing hypoglycemia but are not the immediate intervention for severe cases where prompt elevation of blood glucose levels is necessary.

5. A nurse is administering lorazepam to a client who is scheduled for surgery within 1 hr. Which of the following actions should the nurse take after administering the medication?

• A. Keep the client awake
• B. Instruct the client not to get out of bed
• C. Encourage the client to drink fluids
• D. Encourage early ambulation

Correct answer: B

Rationale: The correct answer is to instruct the client not to get out of bed. Lorazepam is a sedative that can cause drowsiness and impair coordination. By instructing the client not to get out of bed, the nurse helps prevent falls or injuries that could occur due to the medication's sedative effects. Choice A is incorrect as keeping the client awake may not be necessary and could lead to unnecessary discomfort. Choice C is incorrect as encouraging the client to drink fluids is not directly related to the administration of lorazepam. Choice D is incorrect as early ambulation is not safe immediately after administering a sedative medication.

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