Nursing Elites

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

• A. Change the TPN tubing every 72 hours.
• B. Monitor the client's blood glucose every 4 hours.
• C. Monitor the client's urine output every 8 hours.
• D. Use sterile technique when changing the central line dressing.

Correct answer: D

Rationale: The correct answer is D: 'Use sterile technique when changing the central line dressing.' When caring for a client receiving TPN, it is crucial to maintain aseptic technique to prevent infections. Changing the central line dressing with sterile technique helps reduce the risk of introducing pathogens into the client's system. Choices A, B, and C are incorrect because changing the TPN tubing every 72 hours, monitoring blood glucose, and monitoring urine output are important aspects of care but are not directly related to preventing infection in clients receiving TPN.

2. A healthcare provider is reviewing laboratory results for a client who is receiving heparin therapy. Which of the following results indicates that the medication is effective?

• A. Platelets 250,000/mm³
• B. aPTT 60 seconds
• C. Hemoglobin 15 g/dL
• D. INR 1.5

Correct answer: B

Rationale: An aPTT of 60 seconds indicates that the client is receiving an effective dose of heparin. The activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot and is used to monitor heparin therapy. A therapeutic range for aPTT during heparin therapy is usually 1.5 to 2 times the control value, which is around 25-35 seconds. Platelets, hemoglobin, and INR values are not direct indicators of the effectiveness of heparin therapy.

3. What is the priority nursing intervention for a patient with a stage 3 pressure ulcer?

• A. Apply hydrocolloid dressing
• B. Provide wound debridement
• C. Change the dressing daily
• D. Elevate the affected area

Correct answer: A

Rationale: The correct answer is to apply a hydrocolloid dressing. Stage 3 pressure ulcers are characterized by full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, which requires a moist environment for healing. Hydrocolloid dressings help maintain a moist wound environment, promote healing, and provide protection. Providing wound debridement may be necessary but is not the priority intervention at this stage. Changing the dressing daily is important for wound care but not the priority over creating an optimal healing environment. Elevating the affected area can help with circulation and reduce swelling, but it is not the priority intervention for a stage 3 pressure ulcer.

4. A nurse is caring for a client who is 4 hours postoperative following an open reduction and internal fixation of the left tibia. Which of the following findings should the nurse report to the provider?

• A. Serous drainage on the dressing
• B. Capillary refill of 2 seconds
• C. Heart rate of 62/min
• D. Left foot is cool to the touch

Correct answer: D

Rationale: The correct answer is D. A cool left foot indicates impaired circulation, which could be a sign of compartment syndrome or impaired blood flow. This finding should be reported to the provider promptly for further evaluation and intervention. Serous drainage on the dressing is expected postoperatively and is not a concerning finding. A capillary refill of 2 seconds is within the normal range (less than 3 seconds is normal), indicating adequate peripheral perfusion. A heart rate of 62/min is also within the normal range for an adult, suggesting no immediate concern related to the surgery.

5. A healthcare professional is reviewing admission prescriptions for a group of clients. Which of the following prescriptions should the healthcare professional identify as complete?

• A. Furosemide 20 mg BID.
• B. Aspirin 1 tablet daily.
• C. Nitroglycerin transdermal patch.
• D. Metoprolol 5 mg IV now.

Correct answer: D

Rationale: The correct answer is D because it provides the medication (Metoprolol), dosage (5 mg), route of administration (IV), and timing (now), making it a complete prescription. Choices A, B, and C lack either the route of administration or timing, making them incomplete prescriptions. For choice A, it lacks the route of administration, and for choices B and C, they lack the timing of administration.

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