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 nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?

• A. Abdominal cramps
• B. Irritability
• C. Increased thirst
• D. Blurred vision

Correct answer: B

Rationale: Irritability is a common early manifestation of hypoglycemia. When blood glucose levels drop, the brain perceives this as a stressor, leading to irritability. Abdominal cramps (choice A) are not typically associated with hypoglycemia but can occur with other gastrointestinal issues. Increased thirst (choice C) is more indicative of hyperglycemia rather than hypoglycemia. Blurred vision (choice D) is a symptom more commonly associated with hyperglycemia rather than hypoglycemia.

3. A nurse is reviewing the medical record of a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Pain rating of 4 on a scale of 0 to 10
• C. Respiratory rate of 10/min
• D. Temperature of 37.2°C (99°F)

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within acceptable ranges and not indicative of life-threatening complications when administering morphine.

4. A nurse is planning care for a client who is receiving hemodialysis. Which action should the nurse include in the care plan?

• A. Withhold all medications until after dialysis.
• B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
• C. Check the vascular access site for bleeding after dialysis.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial as it helps in detecting and addressing any bleeding complications that may arise from the dialysis procedure. Choice A is incorrect because medications should not be withheld unless specified by the healthcare provider. Choice B is incorrect as dextrose 5% in water is not typically used for orthostatic hypotension. Choice D is incorrect as giving an antibiotic before dialysis is not a routine practice unless specifically prescribed for a particular reason.

5. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

• A. Dehydration is treated with calcium supplements
• B. Dehydration can increase the risk of preterm labor
• C. Dehydration can increase gastroesophageal reflux
• D. Dehydration is caused by a decreased hemoglobin and hematocrit

Correct answer: B

Rationale: The correct statement the nurse should make is that dehydration can increase the risk of preterm labor. Dehydration reduces amniotic fluid and uterine blood flow, potentially leading to preterm contractions. Choice A is incorrect because dehydration is not treated with calcium supplements but rather with adequate fluid intake. Choice C is incorrect as dehydration does not directly increase gastroesophageal reflux. Choice D is incorrect as dehydration is not caused by decreased hemoglobin and hematocrit levels but rather by insufficient fluid intake or excessive fluid loss.

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