Nursing Elites

1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following assessment findings requires immediate intervention by the nurse?

• A. Prealbumin level of 20 mg/dL
• B. Weight increase of 2 kg/day
• C. Temperature of 37.6°C
• D. Blood glucose level of 120 mg/dL

Correct answer: B

Rationale: A rapid weight gain of 2 kg/day suggests fluid overload, a possible complication of TPN. This requires immediate intervention to prevent further complications such as pulmonary edema. The other options are not indicative of immediate complications related to TPN. A low prealbumin level may indicate malnutrition but does not require immediate intervention. A slightly elevated temperature and blood glucose level are within normal ranges and do not warrant immediate action.

2. A nurse is assessing a client who has Clostridium difficile (C. diff) infection. Which infection control measure should the nurse implement?

• A. Wear a face shield when entering the room
• B. Place the client in a private room
• C. Place the client in a negative pressure room
• D. Use alcohol-based hand rub following client care

Correct answer: B

Rationale: The correct answer is to place the client in a private room. Clostridium difficile (C. diff) infection requires contact precautions, which include isolating the client in a private room to prevent the spread of infection to others. Wearing a face shield may be necessary in certain situations for protection but is not the primary measure for C. diff. Placing the client in a negative pressure room is not specifically indicated for C. diff unless the client has additional respiratory issues. Using alcohol-based hand rub following client care is not sufficient for C. diff control; thorough handwashing with soap and water is recommended due to the spore-forming nature of C. diff.

3. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse?

• A. Apologize to the others for your behavior.
• B. I am disappointed that you continue to act out when you are angry.
• C. Come outside with me for a walk.
• D. If you don't calm down, you will have to go into seclusion.

Correct answer: C

Rationale: Offering to go for a walk with the client helps redirect their energy in a non-confrontational way, avoiding escalation of aggressive behavior while promoting de-escalation.

4. A client has been prescribed lithium for bipolar disorder. Which of the following should the nurse teach the client to monitor for signs of toxicity?

• A. Nausea and vomiting
• B. Increased urination
• C. Tremors
• D. Blurred vision

Correct answer: C

Rationale: The correct answer is C: Tremors. Lithium toxicity can present with symptoms such as tremors, nausea, and blurred vision. Tremors are a common early sign of lithium toxicity and should be monitored closely. While nausea and vomiting can also occur with lithium toxicity, tremors are more specific to lithium toxicity. Increased urination is not typically associated with lithium toxicity, and blurred vision is less common compared to tremors in this context.

5. A healthcare professional is preparing to administer an IM injection to a 4-month-old infant. Which of the following injection sites should the healthcare professional use?

• A. Ventrogluteal
• B. Deltoid
• C. Dorsogluteal
• D. Vastus lateralis

Correct answer: D

Rationale: The vastus lateralis is the preferred site for IM injections in infants under 1 year of age because it is well developed and easily accessible compared to other muscle groups. The ventrogluteal and deltoid sites are not typically used for infants due to muscle development and size. The dorsogluteal site is not recommended for infants or young children due to its proximity to major nerves and blood vessels.

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