Nursing Elites

1. A client who has a new prescription for lithium is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. ''I will avoid eating foods that contain tyramine.''
• B. ''I should increase my salt intake while taking this medication.''
• C. ''I should drink at least 2 liters of water each day while taking this medication.''
• D. ''I should avoid consuming caffeinated beverages while taking this medication.''

Correct answer: C

Rationale: The correct answer is C. Drinking at least 2 liters of water daily is crucial for clients taking lithium to prevent dehydration and lithium toxicity. Lithium is a salt, so it's important for clients to maintain adequate hydration. Option A is incorrect because lithium does not interact with tyramine-containing foods. Option B is incorrect because increasing salt intake is not necessary and can actually exacerbate lithium toxicity. Option D is incorrect because avoiding caffeinated beverages is not a priority teaching point for clients taking lithium.

2. What is the best way to monitor for infection in a patient with a central line?

• A. Check the central line site daily
• B. Monitor the patient's vital signs
• C. Check the central line dressing every other day
• D. Check for signs of sepsis

Correct answer: A

Rationale: The correct answer is A: Check the central line site daily. Monitoring the central line site daily is crucial in detecting early signs of infection, such as redness, swelling, tenderness, or drainage. By checking the site regularly, healthcare providers can take prompt action to prevent complications. Choice B, monitoring the patient's vital signs, while important in assessing overall health, may not specifically indicate an infection related to the central line. Choice C, checking the central line dressing every other day, may not be frequent enough to catch early signs of infection. Choice D, checking for signs of sepsis, is important but represents a more severe stage of infection and may occur after local signs at the central line site have already manifested.

3. 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.

4. What is the best position for a patient with respiratory distress?

• A. Semi-Fowler's position
• B. Trendelenburg position
• C. Prone position
• D. Supine position

Correct answer: A

Rationale: The best position for a patient with respiratory distress is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Trendelenburg position, where the patient's feet are higher than the head, is contraindicated in respiratory distress as it can increase pressure on the diaphragm and compromise breathing. The prone position, lying face down, may be beneficial in certain cases like acute respiratory distress syndrome but is not generally recommended for all patients in respiratory distress. The supine position, lying flat on the back, can worsen respiratory distress by causing the tongue to fall back and obstruct the airway.

5. A nurse is caring for a client who is receiving enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?

• A. Flush the tube with 30 mL of sterile water before each feeding
• B. Administer the feeding using a large-bore syringe
• C. Keep the head of the bed elevated to 15 degrees
• D. Replace the feeding bag every 24 hours

Correct answer: A

Rationale: The correct action for the nurse to take is to flush the tube with 30 mL of sterile water before each feeding. This helps maintain tube patency and prevents clogs. Choice B is incorrect because enteral feedings should be administered using a gravity drip method or a pump, not through a large-bore syringe. Choice C is incorrect because the head of the bed should be elevated to at least 30 degrees to reduce the risk of aspiration. Choice D is incorrect because the feeding bag should be replaced every 24 hours to prevent bacterial contamination.

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