Nursing Elites

1. A healthcare provider is planning care for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the healthcare provider include?

• A. Administer 0.9% sodium chloride with the TPN.
• B. Change the TPN tubing every 24 hours.
• C. Weigh the client every 72 hours.
• D. Flush the TPN line with heparin.

Correct answer: B

Rationale: The correct action the healthcare provider should include is changing the TPN tubing every 24 hours to decrease the risk of infection. Administering 0.9% sodium chloride with TPN is not typically recommended as it can cause chemical instability. Weighing the client every 72 hours is important but not directly related to TPN administration. Flushing the TPN line with heparin is not a standard practice and not recommended as it can increase the risk of complications.

2. What is the most important assessment for a patient with respiratory distress?

• A. Monitor oxygen saturation
• B. Check for abnormal breath sounds
• C. Check for pitting edema
• D. Perform a neurological exam

Correct answer: A

Rationale: Monitoring oxygen saturation is crucial in assessing a patient with respiratory distress because it helps determine if the patient is receiving adequate oxygen. Oxygen saturation levels provide immediate feedback on the efficiency of oxygen delivery to the tissues. Checking for abnormal breath sounds (Choice B) is relevant in respiratory assessments, but it is secondary to assessing oxygen saturation. Pitting edema (Choice C) and performing a neurological exam (Choice D) are not directly related to assessing respiratory distress and are not the primary focus when managing a patient with breathing difficulties.

3. A nurse is providing discharge instructions for a client who has osteoporosis. Which of the following instructions should the nurse include to prevent injury?

• A. Perform weight-bearing exercises.
• B. Avoid crossing the legs beyond the midline.
• C. Avoid sitting in one position for prolonged periods.
• D. Splint the affected area.

Correct answer: A

Rationale: The correct answer is A: Perform weight-bearing exercises. Weight-bearing exercises are crucial for preventing bone density loss in clients with osteoporosis. These exercises help strengthen bones and reduce the risk of fractures. Option B, avoiding crossing the legs beyond the midline, is not directly related to preventing injury in osteoporosis. Option C, avoiding sitting in one position for prolonged periods, is important for preventing pressure ulcers but does not specifically address preventing injury in osteoporosis. Option D, splinting the affected area, is not a standard recommendation for preventing injury in osteoporosis.

4. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?

• A. Placing a belt restraint on a school-age child who has seizures.
• B. Securing wrist restraints to the bed rails for an adolescent.
• C. Applying elbow immobilizers to an infant receiving cleft lip injury.
• D. Keeping the side rails of a toddler's crib elevated.

Correct answer: D

Rationale: The correct answer is D. Keeping the side rails of a toddler's crib elevated is an appropriate use of restraints to prevent the child from falling, which is an essential safety measure. Placing a belt restraint on a school-age child with seizures (choice A) is not recommended as it can be dangerous during a seizure. Securing wrist restraints to the bed rails for an adolescent (choice B) may cause harm and should not be done routinely. Applying elbow immobilizers to an infant receiving a cleft lip injury (choice C) is not a standard practice for managing this condition and would not be appropriate.

5. A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the nurse report to the provider?

• A. Respiratory rate of 20/min
• B. Oxygen saturation of 93%
• C. Pain level of 2 on a scale of 0 to 10
• D. Blood pressure of 110/70 mm Hg

Correct answer: D

Rationale: The correct answer is D because a blood pressure drop or other signs of morphine overdose should be reported, especially when using a PCA pump. Choices A, B, and C are within normal limits and do not indicate an immediate concern related to morphine administration.

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