Nursing Elites

1. A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

• A. Glucose 180 mg/dL
• B. Sodium 136 mEq/L
• C. Potassium 3.8 mEq/L
• D. Albumin 3.5 g/dL

Correct answer: A

Rationale: The correct answer is A: "Glucose 180 mg/dL." Elevated glucose levels in a client receiving TPN may indicate hyperglycemia, which can lead to complications such as osmotic diuresis, dehydration, and electrolyte imbalances. It is essential to report this finding to the provider for further evaluation and management. Choices B, C, and D are within normal ranges and do not indicate immediate concerns related to TPN administration.

2. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching?

• A. Remove the protective gown after leaving the client's room
• B. Place the client in a room with positive pressure
• C. Wear gloves when providing care to the client
• D. Wear a mask when entering the client's room

Correct answer: C

Rationale: The correct measure to include when caring for a client on contact precautions is to wear gloves when providing care. Gloves help prevent the spread of infection and cross-contamination. Choice A is incorrect because the protective gown should be removed before leaving the client's room to prevent the spread of pathogens. Choice B is incorrect as clients on contact precautions should be in a room with negative pressure to prevent the spread of airborne contaminants. Choice D is incorrect as wearing a mask when changing linens is not specifically required for contact precautions.

3. A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

• A. Auscultate the apical pulse and count for 1 minute
• B. Place a sensor on the index finger
• C. Heat the skin prior to placing the probe
• D. Recheck after 10 minutes

Correct answer: A

Rationale: Corrected Rationale: Auscultating the apical pulse and counting for one minute is the appropriate method to accurately measure a newborn's heart rate. The apical pulse is located at the point of maximum impulse (PMI), which is usually at the fourth or fifth intercostal space along the mid-clavicular line. This method allows for a precise assessment of the newborn's heart rate. Choice B, placing a sensor on the index finger, is incorrect because this method is more suitable for measuring oxygen saturation rather than heart rate. Choice C, heating the skin prior to placing the probe, is unnecessary for assessing heart rate and may lead to potential burns in newborns. Choice D, rechecking after 10 minutes, is not appropriate as immediate assessment and intervention may be required if an abnormal heart rate is detected in a newborn.

4. A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following actions should the nurse take?

• A. Clamp the chest tube when assisting the client out of bed.
• B. Empty the drainage system every 8 hours.
• C. Keep the collection device below the client's chest.
• D. Strip the chest tube every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to keep the collection device below the client's chest. This positioning ensures proper drainage of fluid from the chest, preventing backflow of fluids. Clamping the chest tube when assisting the client out of bed is incorrect as it can lead to fluid accumulation and potential complications. Emptying the drainage system every 8 hours is necessary but not the priority over maintaining proper positioning. Stripping the chest tube every 4 hours is an outdated practice and can cause damage to the tissue and should be avoided.

5. A nurse is caring for a client with Alzheimer's disease who wanders frequently. Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in a well-lit area to reduce wandering.
• B. Ensure that the client wears an identification bracelet at all times.
• C. Keep the client's bed in the lowest position.
• D. Use physical restraints to prevent wandering.

Correct answer: B

Rationale: The correct answer is to ensure that the client wears an identification bracelet at all times. This intervention helps staff recognize clients who wander and ensures their safety. Placing the client in a well-lit area (Choice A) may be helpful in some cases but does not directly address the issue of wandering. Keeping the client's bed in the lowest position (Choice C) is important for fall prevention but is not directly related to wandering behavior. Using physical restraints (Choice D) is not recommended as the first-line intervention for wandering and should be avoided due to ethical concerns and potential risks.

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