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. A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

• A. Place the tip of the thermometer under the center of the infant's axilla.
• B. Pull the pinna of the infant's ear forward before inserting the probe.
• C. Insert the probe 3.8 cm (1.5 inches) into the infant's rectum.
• D. Insert the thermometer in front of the infant's tongue.

Correct answer: A

Rationale: The correct method for measuring an infant's temperature is by placing the tip of the thermometer under the center of the infant's axilla (armpit). This method is non-invasive and safe. Pulling the pinna of the ear forward is used when taking a tympanic temperature. Inserting the probe into the rectum is done for rectal temperature measurement, which is not recommended as an initial method in infants. Inserting the thermometer in front of the infant's tongue is not a standard method for measuring temperature in infants.

3. A nurse is teaching a client who has a new prescription for captopril. Which of the following instructions should the nurse include?

• A. Take this medication with food.
• B. Take this medication 1 hour before meals.
• C. Avoid potassium supplements while taking this medication.
• D. You may experience a persistent, dry cough while taking this medication.

Correct answer: D

Rationale: The correct answer is D. Captopril is known to cause a persistent, dry cough as a common side effect. Instructing the client about this potential side effect is crucial for their awareness. Choices A and B are incorrect because captopril is usually taken on an empty stomach. Choice C is incorrect because captopril can lead to hyperkalemia, so potassium supplements may be necessary in some cases.

4. What is the most concerning electrolyte imbalance for a patient receiving digoxin?

• A. Hyperkalemia
• B. Hypokalemia
• C. Hyponatremia
• D. Hypercalcemia

Correct answer: B

Rationale: The correct answer is Hypokalemia. Hypokalemia is the most concerning electrolyte imbalance for a patient receiving digoxin because it can increase the risk of digoxin toxicity. Low potassium levels can potentiate the effects of digoxin on the heart, leading to serious cardiac arrhythmias. Hyperkalemia (Choice A) is not typically associated with digoxin use. Hyponatremia (Choice C) and Hypercalcemia (Choice D) are not directly related to digoxin therapy and do not pose the same risk of toxicity.

5. A nurse is assessing a client who is receiving opioid analgesics for pain management. Which of the following findings should the nurse report to the provider?

• A. Respiratory rate of 20/min
• B. Blood pressure of 118/76 mm Hg
• C. Heart rate of 88/min
• D. Oxygen saturation of 94%

Correct answer: C

Rationale: The correct answer is C. A heart rate of 88/min is a normal finding; therefore, it does not require immediate reporting to the provider. The respiratory rate of 20/min, blood pressure of 118/76 mm Hg, and oxygen saturation of 94% are also within normal ranges and do not indicate any immediate concerns. However, a serum potassium level of 3.0 mEq/L indicates hypokalemia, which can be a serious issue and should be reported to the provider for further evaluation and management.

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