Nursing Elites

1. Nurses caring for four clients. Which of the following client data should the nurse report to the provider?

• A. A client who has pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing
• B. Client drained a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24 hours following surgery
• C. Client who is 4 hours postoperative and has a heart rate of 98 per minute
• D. The client has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3

Correct answer: D

Rationale: The correct answer is D. The client with chemotherapy and a low neutrophil count is at risk for infection and requires prompt intervention. Reporting this information to the provider is crucial to ensure appropriate monitoring and management to prevent potential complications. Choices A, B, and C do not indicate an immediate risk that requires immediate provider notification. A client reporting pain with pleurisy, a client draining fluid post-surgery, or a client with a heart rate of 98 per minute postoperative are not urgent enough to warrant immediate reporting compared to the client at risk for infection.

2. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?

• A. Place food on the left side of the client's mouth when they are ready to eat
• B. Provide assistance with the client's ADLs
• C. Maintain the client in an upright position
• D. Place the client's left arm on a pillow while they are sitting

Correct answer: D

Rationale: Placing the client's left arm on a pillow while they are sitting helps prevent shoulder displacement and provides support for the limb post-stroke. This positioning is important to maintain proper alignment and prevent complications. Choices A, B, and C are incorrect because placing food on the left side of the mouth, providing total assistance with ADLs, and maintaining the client on bed rest do not directly address the specific needs related to unilateral paralysis and dysphagia post right hemispheric stroke.

3. While caring for a client receiving total parenteral nutrition (TPN), which of the following actions should the nurse take?

• A. Monitor the client's urine output every 8 hours.
• B. Administer a bolus of 0.9% sodium chloride.
• C. Check the client's blood glucose level every 4 hours.
• D. Flush the TPN line with sterile water before and after administration.

Correct answer: C

Rationale: Checking the client's blood glucose level every 4 hours is essential when managing a client on TPN to monitor for hyperglycemia, a common complication. Monitoring urine output (Choice A) is important but not a priority in this scenario. Administering a bolus of 0.9% sodium chloride (Choice B) is not indicated as it is unrelated to managing TPN. Flushing the TPN line with sterile water (Choice D) is necessary, but it should be done with 0.9% sodium chloride, not water.

4. A nurse is preparing to administer dopamine hydrochloride 4 mcg/kg/min via continuous infusion. The client weighs 80 kg. How many mL/hr should the nurse set the IV infusion to deliver?

• A. 6 mL/hr
• B. 8 mL/hr
• C. 12 mL/hr
• D. 16 mL/hr

Correct answer: A

Rationale: To calculate the correct rate, use the formula: (4 mcg/kg/min * 80 kg) / 800 mcg in 250 mL = 6 mL/hr. This calculation is based on the dose ordered (4 mcg/kg/min) multiplied by the patient's weight in kg (80 kg), divided by the concentration of the drug available (800 mcg in 250 mL) to be infused over 1 hour. Therefore, the correct answer is 6 mL/hr. Choices B, C, and D are incorrect as they do not reflect the accurate calculation based on the provided information.

5. A client is receiving radiation therapy to the head and neck. Which of the following interventions should the nurse include?

• A. Instruct the client to use an alcohol-free mouthwash.
• B. Apply heat packs to the radiation site.
• C. Provide a diet low in carbohydrates.
• D. Avoid exposure to direct sunlight during treatment.

Correct answer: D

Rationale: The correct intervention for a client receiving radiation therapy to the head and neck is to avoid exposure to direct sunlight. Direct sunlight should be avoided to protect the skin from further irritation and damage caused by the radiation therapy. Instructing the client to use an alcohol-free mouthwash is important to prevent irritation and maintain oral hygiene, making choice A incorrect. Applying heat packs to the radiation site is contraindicated as heat can further aggravate the skin, making choice B incorrect. Providing a diet low in carbohydrates is not directly related to radiation therapy to the head and neck, so choice C is also incorrect.

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