Nursing Elites

1. The healthcare provider is assessing a client who is receiving total parenteral nutrition (TPN). Which finding requires immediate intervention?

• A. Blood glucose level of 150 mg/dL.
• B. Weight gain of 2 pounds in 24 hours.
• C. Decreased urine output.
• D. Temperature of 100.3°F (37.9°C).

Correct answer: C

Rationale: Decreased urine output in a client receiving total parenteral nutrition (TPN) requires immediate intervention because it can indicate potential complications such as fluid overload or kidney dysfunction. Monitoring urine output is crucial in assessing renal function and fluid balance in patients on TPN. A blood glucose level of 150 mg/dL is within a normal range and may not require immediate intervention. Weight gain of 2 pounds in 24 hours could be a concern but may not be as urgent as addressing decreased urine output. A temperature of 100.3°F (37.9°C) is slightly elevated but may not be directly related to TPN administration unless there are other symptoms of infection present.

2. The nurse is developing a community health program to address the high rates of hypertension in a neighborhood. Which intervention should the nurse prioritize?

• A. conducting free blood pressure screenings
• B. distributing educational materials on hypertension
• C. holding workshops on stress management
• D. partnering with local gyms to offer discounted memberships

Correct answer: A

Rationale: Conducting free blood pressure screenings should be prioritized as it helps identify individuals with hypertension who may not be aware of their condition. Early detection allows for timely medical intervention and management. While distributing educational materials, holding stress management workshops, and partnering with local gyms are valuable interventions, they may not directly address the immediate need for identifying undiagnosed cases of hypertension in the community.

3. A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, 'Why do you have to wear a gown and mask when you are in my room?' How should the nurse respond?

• A. To protect myself from your germs.
• B. To protect you because you can get an infection very easily.
• C. Until your white blood cell count increases.
• D. To keep others from getting your infection.

Correct answer: B

Rationale: Reverse isolation precautions protect the client from exposure to microorganisms from others.

4. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take if a client is exhibiting an extrapyramidal reaction to psychotropic medications?

• A. Leave a detailed message about the client's condition.
• B. Tell the receptionist to have the healthcare provider return the phone call.
• C. Call another healthcare provider.
• D. Document the attempt to call the healthcare provider.

Correct answer: B

Rationale: The best nursing action is to request a return call from the healthcare provider. When a client is experiencing an extrapyramidal reaction to psychotropic medications, it is crucial to prioritize the client's confidentiality and ensure the information is conveyed to the healthcare provider directly. Leaving a detailed message with a receptionist may compromise the confidentiality of the client's condition. Calling another healthcare provider may delay necessary intervention and continuity of care. Documenting the attempt to call is important for the nurse's records but does not address the immediate need to inform the healthcare provider about the client's condition.

5. The school nurse is coaching a group of high school students on ways to deal with the stress of final exams. Today the class is focusing on healthy food choices for lunch in the school cafeteria. Which option should the nurse recommend?

• A. cheeseburger on a whole wheat bun, French fries, and a large cola beverage
• B. tuna casserole with peas and corn, a fresh apple, crackers, and orange juice
• C. fruit salad with fresh berries and oranges, chicken vegetable soup, and tea
• D. chef salad with turkey, ham, and ranch dressing, apple juice, and milk

Correct answer: C

Rationale: The recommended option for managing stress during final exams is a balanced and nutritious meal. Fruit salad with fresh berries and oranges, chicken vegetable soup, and tea offer a variety of nutrients and antioxidants that can help combat stress. Option A is not ideal as it includes high-fat and high-calorie foods. Option B is a good choice, but Option C provides a wider range of nutrients and hydration. Option D is a healthy choice with a variety of proteins and vitamins, but Option C offers lighter options that may be easier to digest during stressful times.

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