Nursing Elites

1. A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following actions should the nurse take?

• A. Administer the TPN solution separately from 0.9% sodium chloride
• B. Check for an allergy to eggs
• C. Discuss the TPN solution with the client
• D. Monitor for hypoglycemia

Correct answer: B

Rationale: The correct action for the nurse to take when preparing to administer TPN with fat supplements is to check for an allergy to eggs. The lipid emulsion in TPN often contains egg phospholipids, so screening for egg allergies is crucial to prevent any adverse reactions. Option A is incorrect because TPN should not be piggybacked with 0.9% sodium chloride to avoid any interactions or dilution of the TPN solution. Option C is incorrect as discussing the TPN solution with the client is not the priority when preparing to administer it. Option D is incorrect as monitoring for hypoglycemia, although important in TPN administration, is not specifically related to the addition of fat supplements.

2. A nurse is assessing a client who has a history of atrial fibrillation and is receiving warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the warfarin?

• A. Platelet count
• B. International normalized ratio (INR)
• C. Bleeding time
• D. Partial thromboplastin time (PTT)

Correct answer: B

Rationale: The correct answer is B: International normalized ratio (INR). The INR is used to monitor the effectiveness of warfarin therapy. A higher INR indicates a longer time it takes for the blood to clot, which is desirable in patients receiving warfarin to prevent blood clots. Platelet count (Choice A) assesses the number of platelets in the blood and is not directly related to warfarin therapy. Bleeding time (Choice C) evaluates the time it takes for a person to stop bleeding after a standardized wound, but it is not specific to monitoring warfarin effectiveness. Partial thromboplastin time (PTT) (Choice D) is more commonly used to monitor heparin therapy, not warfarin.

3. A nurse is assessing a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?

• A. Blood glucose 120 mg/dL
• B. pH 7.32
• C. HCO3 25 mEq/L
• D. PaCO2 48 mm Hg

Correct answer: B

Rationale: The correct answer is B. A pH of 7.32 indicates metabolic acidosis, which is a hallmark of diabetic ketoacidosis (DKA). In DKA, blood glucose levels are typically elevated, bicarbonate levels are often low, and there is a compensatory respiratory response leading to a decrease in PaCO2. Option A is incorrect because a blood glucose level of 120 mg/dL is within the normal range and not indicative of DKA. Option C is incorrect because an HCO3 level of 25 mEq/L is not typically seen in DKA where bicarbonate levels are usually lower. Option D is incorrect because a PaCO2 of 48 mm Hg would not be expected in DKA; it would typically be lower due to compensatory respiratory alkalosis.

4. A client newly diagnosed with osteoporosis is being taught by a nurse about preventing complications. Which food should the nurse recommend?

• A. Fried chicken
• B. Whole milk
• C. Oatmeal
• D. Bacon

Correct answer: C

Rationale: Oatmeal is an excellent recommendation for clients with osteoporosis due to its richness in fiber and nutrients, making it a heart-healthy and bone-friendly choice. Fried chicken (Choice A) is high in unhealthy fats and lacks the nutrients needed for bone health. Whole milk (Choice B) contains calcium but can be high in saturated fats, which may not be the best choice for individuals with osteoporosis. Bacon (Choice D) is high in saturated fats and sodium, which can have negative effects on bone health and overall well-being.

5. A client has been prescribed phenytoin. Which of the following should the nurse monitor to prevent toxicity?

• A. Blood pressure
• B. Complete blood count
• C. Serum phenytoin levels
• D. Liver function tests

Correct answer: C

Rationale: Corrected Rationale: Serum phenytoin levels should be regularly monitored to prevent toxicity because the therapeutic range is narrow. Monitoring blood pressure (choice A), complete blood count (choice B), and liver function tests (choice D) are not directly related to preventing phenytoin toxicity.

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