Nursing Elites

1. The nurse is providing care for a client who is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse monitor closely to assess for complications?

• A. Serum potassium
• B. Blood glucose
• C. Serum sodium
• D. Serum calcium

Correct answer: B

Rationale: The correct answer is B: Blood glucose. When caring for a client receiving total parenteral nutrition (TPN), monitoring blood glucose levels is essential due to the increased risk of hyperglycemia associated with TPN infusion. Elevated blood glucose levels can lead to complications such as hyperglycemia, which can be harmful to the client. While monitoring serum potassium (Choice A), serum sodium (Choice C), and serum calcium (Choice D) are also important aspects of care, when specifically considering TPN administration, blood glucose monitoring takes precedence due to the potential for significant complications related to glucose imbalances.

2. A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?

• A. A client who has new onset of dyspnea 24 hours after a total hip arthroplasty
• B. A client who has acute abdominal pain rated 4 on a scale from 0 to 10
• C. A client who has a UTI and low-grade fever
• D. A client who has pneumonia and an oxygen saturation of 96%

Correct answer: A

Rationale: The nurse should see the client who has new onset of dyspnea 24 hours after a total hip arthroplasty first. New onset of dyspnea, especially after surgery, can indicate a serious complication such as a pulmonary embolism or deep vein thrombosis. It is essential to assess this client promptly to rule out potentially life-threatening conditions. Acute abdominal pain, a UTI with low-grade fever, and pneumonia with an oxygen saturation of 96% are important issues but do not indicate the urgency and potential severity of a post-operative complication like pulmonary embolism or deep vein thrombosis.

3. During a dressing change, a healthcare professional observes granulation tissue in a client's wound. Which of the following findings should be documented?

• A. Stringy, white tissue
• B. Translucent, red tissue
• C. Soft, yellow tissue
• D. Thick, black tissue

Correct answer: B

Rationale: Granulation tissue is a hallmark of healing in wounds. It appears as translucent and red, indicating angiogenesis and the formation of new blood vessels in the wound bed. This tissue is vital for wound healing as it provides a scaffold for cell migration and promotes re-epithelialization. Choices A, C, and D do not describe granulation tissue accurately. Stringy, white tissue may suggest fibrin, soft, yellow tissue could indicate slough, and thick, black tissue may imply necrotic tissue, all of which are not synonymous with granulation tissue and do not signify the healing process.

4. A client reports increased pain following physical therapy. Which of the following questions should the nurse ask to assess the quality of the pain?

• A. Is the pain sharp or dull?
• B. Does the pain feel like burning or aching?
• C. Is the pain constant or intermittent?
• D. Does the pain feel like throbbing or stabbing?

Correct answer: A

Rationale: When assessing pain quality, asking if the pain is sharp or dull helps determine the nature of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate a chronic issue. Choices B, C, and D are incorrect as they do not directly address the quality of the pain in terms of sharpness or dullness.

5. A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?

• A. Fidelity
• B. Autonomy
• C. Beneficence
• D. Justice

Correct answer: A

Rationale: The correct answer is A: Fidelity. Fidelity in nursing ethics involves keeping promises and being faithful to commitments, demonstrating reliability and trustworthiness. In this scenario, the nurse is exemplifying fidelity by returning promptly to the client as promised. Choice B, Autonomy, refers to respecting a patient's right to make their own decisions, not relevant in this situation. Choice C, Beneficence, involves the duty to act in the best interest of the patient, which is not the primary focus here. Choice D, Justice, pertains to fairness and equity in the distribution of healthcare resources, not applicable to the nurse's actions in this case.

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