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 client prescribed clozapine is receiving discharge teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “I should report a sore throat to my provider.”
• B. “I should avoid drinking grapefruit juice while taking this medication.”
• C. “I should take this medication with food.”
• D. “I should avoid taking this medication with food.”

Correct answer: A

Rationale: The correct answer is A. Clozapine can cause agranulocytosis, a serious condition that decreases the number of white blood cells. Reporting a sore throat is crucial as it could be a sign of infection. Choice B is incorrect because there is no specific interaction between clozapine and grapefruit juice. Choice C is incorrect because clozapine is usually taken without regard to meals. Choice D is incorrect as clozapine is generally taken without food to enhance absorption.

3. A client with heart failure is receiving digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 78/min.
• B. Vision changes.
• C. Respiratory rate of 16/min.
• D. Blood pressure of 120/80 mm Hg.

Correct answer: B

Rationale: The correct answer is B: Vision changes. Vision changes are a classic sign of digoxin toxicity and should be reported immediately to the provider for further evaluation and management. A heart rate of 78/min, a respiratory rate of 16/min, and a blood pressure of 120/80 mm Hg are within normal ranges and are not typically associated with digoxin toxicity. Therefore, they would not be the priority findings to report in this situation.

4. A client has a new prescription for levothyroxine. Which of the following instructions should the nurse include?

• A. Take this medication in the evening before bed.
• B. Take this medication on an empty stomach.
• C. Take this medication with a full glass of milk.
• D. Take this medication with an antacid if you experience indigestion.

Correct answer: B

Rationale: The correct instruction when taking levothyroxine is to take it on an empty stomach. This enhances absorption and ensures the medication's effectiveness. Taking it with food or other substances, such as milk or antacids, can interfere with its absorption. Therefore, choices A, C, and D are incorrect.

5. A nurse is assessing a client who is postoperative following a total knee arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Capillary refill of 2 seconds
• C. Wound drainage of 30 mL in 8 hours
• D. Warmth and redness in the calf

Correct answer: D

Rationale: The correct answer is D. Warmth and redness in the calf are indicative of a possible deep vein thrombosis (DVT), a serious complication post-surgery that requires immediate attention. Reporting this finding promptly to the provider is crucial for timely intervention. Choices A, B, and C are within normal limits for a postoperative client and do not indicate a potentially life-threatening condition like DVT.

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